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Total Results: 3,913 records

Showing results for "skill".

3721. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
      psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
      March 09, 2022 - Dural tears during lumbar spinal endoscopy: surgeon skill, training, incidence, risk factors, and management

3722. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60790/psn-pdf
      February 23, 2022 - based active errors (e.g., misdiagnosis), rule-based active errors (e.g., forgetting instructions), or skill

3723. Transfusion Overload | PSNet
      psnet.ahrq.gov/web-mm/transfusion-overload
      September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

3724. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - Missed CANDOR Implementation Opportunities. Citation Text: Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndN…

3725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852698/psn-pdf
      August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…

3726. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout | PSNet
      psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
      January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout Citation Text: Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

3727. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet
      psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
      January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…

3728. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
      psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
      September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures Citation Text: Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …

3729. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866055/psn-pdf
      May 29, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle Summary Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common catego…

3730. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet
      psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
      June 28, 2023 - SPOTLIGHT CASE Prolonged DKA in Pregnancy: A Case of Communication Breakdown. Citation Text: Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…

3731. Implementing a Fall Prevention Program | PSNet
      psnet.ahrq.gov/perspective/implementing-fall-prevention-program
      November 29, 2023 - Implementing a Fall Prevention Program Frances Healey, RN, PhD | December 1, 2011  View more articles from the same authors. Citation Text: Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

3732. Pregnant With Danger | PSNet
      psnet.ahrq.gov/web-mm/pregnant-danger
      January 12, 2011 - Pregnant With Danger Citation Text: Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

3733. Crossing the Line | PSNet
      psnet.ahrq.gov/web-mm/crossing-line
      December 01, 2012 - SPOTLIGHT CASE Crossing the Line Citation Text: Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

3734. The Case of Mistaken Intubation | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-intubation
      July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX End…

3735. A Weighty Mistake | PSNet
      psnet.ahrq.gov/web-mm/weighty-mistake
      September 01, 2016 - SPOTLIGHT CASE A Weighty Mistake Citation Text: Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

3736. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74713/psn-pdf
      January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…

3737. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
      January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…

3738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72835/psn-pdf
      March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021 In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Cente…

3739. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842919/psn-pdf
      February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …

3740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49519/psn-pdf
      September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…