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Total Results: 233 records

Showing results for "subject".

81. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
    June 01, 2005 - The first was that our institution had several adverse events—one involving a healthy research subject

82. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836839/psn-pdf
    March 31, 2022 - To further explore the topic, we engaged Mary Beth Kingston, PhD, RN, FAAN, a subject matter expert

83. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
    psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Take Home Points Necrotizing soft tissue infections are often subject to delayed diagnosis, since … These systems appear to be inextricably linked in diagnostic reasoning, although the former may be more subject

84. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837659/psn-pdf
    July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging July 8, 2022 Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging The Cases Case #1: A 42-year-old woman admitted with…

85. Defensive Medicine: "Glowing" with Pain | PSNet
    psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
    November 01, 2012 - Defensive Medicine: "Glowing" with Pain Citation Text: Sethi MK. Defensive Medicine: "Glowing" with Pain. 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 E…

86. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - Citation Editor’s note: Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ, is a high reliability subject … Jessica Behrhorst:  I am currently working as a high reliability subject matter expert at Aptive Resources

87. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet
    psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - therapeutic guidelines) all make retrospective assessments of "diagnosability" or "preventability" of harm subject … Human reasoning is subject to computational limitations and biasing factors that cause specific types

88. Annual Perspective: Psychological Safety of Healthcare Staff | PSNet
    psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
    November 16, 2022 - To further explore the topic, we engaged Mary Beth Kingston, PhD, RN, FAAN, a subject matter expert in

89. 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…

90. Medication Safety Events Related to Diagnostic Imaging | PSNet
    psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
    January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging Citation Text: Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

91. Measuring and Responding to Deaths From Medical Errors | PSNet
    psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
    April 01, 2008 - Preventable Adverse Events The number of patients who die due to medical errors has been a controversial subject

92. Accountability in Patient Safety | PSNet
    psnet.ahrq.gov/perspective/accountability-patient-safety
    January 01, 2018 - espoused in the early years of the safety movement and the need for individual accountability has been a subject

93. Retained Surgical Items: Causation and Prevention | PSNet
    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - are a time-honored preventive measure, they are heavily dependent on human performance and are thus subject … technological adjuncts have been invented, but these approaches also depend on human performance and are subject

94. Radiation Safety | PSNet
    psnet.ahrq.gov/primer/radiation-safety
    September 15, 2024 - Current Context Like all issues that have been the subject of Sentinel Event Alerts, radiation safety

95. Did We Forget Something? | PSNet
    psnet.ahrq.gov/web-mm/did-we-forget-something
    April 28, 2021 - time-honored, simple preventive measure, it is heavily dependent on human performance practices and is thus subject

96. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet
    psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - are required to disclose relevant financial relationships with commercial interests related to the subject … The choice of the kind of dressing to use is subject to physicians’ judgment and preference, but for

97. Collegiality vs. Competence | PSNet
    psnet.ahrq.gov/web-mm/collegiality-vs-competence
    August 28, 2024 - concern was raised about the appropriateness of care in these instances that the surgeon had been the subject

98. Building a Safety Program Using Principles of Resilience Engineering | PSNet
    psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
    October 23, 2013 - Is safety a subject for science? Safety Sci. 2014;67:21-24. [Available at] 2.

99. Technical Expert Panel | PSNet
    psnet.ahrq.gov/Information/Panel
    January 01, 2012 - The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject

100. Editorial Team | PSNet
     psnet.ahrq.gov/Information/Editor
     The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that