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Showing results for "situations".

2641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49459/psn-pdf
      September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …

2642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49466/psn-pdf
      October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …

2643. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49818/psn-pdf
      January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis January 1, 2018 Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis The Case A 50-year-old man presented to a primary care clinic to establish care, as he ha…

2644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72693/psn-pdf
      January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

2645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33695/psn-pdf
      April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance April 1, 2010 Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010. ht…

2646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867849/psn-pdf
      February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

2647. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

2648. An Easily Forgotten Tube | PSNet
      psnet.ahrq.gov/web-mm/easily-forgotten-tube
      June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

2649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33699/psn-pdf
      August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…

2650. Too Many Cooks Spotlight Pdf (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
      January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…

2651. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49493/psn-pdf
      November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…

2652. Failure to Reevaluate | PSNet
      psnet.ahrq.gov/web-mm/failure-reevaluate
      February 01, 2014 - Failure to Reevaluate Citation Text: Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

2653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49835/psn-pdf
      January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…

2654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851158/psn-pdf
      June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization June 28, 2023 Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization The Case A patient was …

2655. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33651/psn-pdf
      June 01, 2007 - In Conversation with...Diane Rydrych, MA June 1, 2007 In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health,…

2656. Saved by ECMO | PSNet
      psnet.ahrq.gov/web-mm/saved-ecmo
      May 05, 2017 - Saved by ECMO Citation Text: Weiss NA. Saved by ECMO . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49523/psn-pdf
      November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…

2658. Coming Up Short: Maintaining Safety in the Face of Drug Shortages | PSNet
      psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
      November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages Citation Text: Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

2659. The Deadly Duo | PSNet
      psnet.ahrq.gov/web-mm/deadly-duo
      April 28, 2021 - Situations that merit referral to psychiatrists include: when the first-line drug cannot be tolerated

2660. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. | PSNet
      psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
      March 03, 2021 - left upper quadrant (or, in select cases, the right upper quadrant) offer safe alternatives in these situations