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Showing results for "techniques".

1661. Walking Patient, Missing Drain | PSNet
      psnet.ahrq.gov/web-mm/walking-patient-missing-drain
      April 01, 2006 - Walking Patient, Missing Drain Citation Text: Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote …

1662. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable Citation Text: Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy C…

1663. Point-of-care Mixup: 1 Shot Turns Into 3 | PSNet
      psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
      February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3…

1664. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73335/psn-pdf
      May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

1665. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49607/psn-pdf
      August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…

1666. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

1667. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49739/psn-pdf
      August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…

1668. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33665/psn-pdf
      March 01, 2008 - Creation of a Medical Procedure Service to Improve Patient Safety March 1, 2008 Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety Perspective Introduction and …

1669. 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, …

1670. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33639/psn-pdf
      September 01, 2006 - In Conversation with...James P. Bagian, MD September 1, 2006 In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Where did your interest in safety come from? Dr. James Bagian: I don't know …

1671. Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes | PSNet
      psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
      February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 29, 2023 Innovation Co…

1672. Situational Awareness and Patient Safety | PSNet
      psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
      May 01, 2012 - Situational Awareness and Patient Safety Citation Text: Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

1673. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-472
      February 26, 2025 - February 26, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repor…

1674. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38688/psn-pdf
      June 03, 2009 - Empowered to improve. June 3, 2009 Gardner E. https://psnet.ahrq.gov/issue/empowered-improve This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry. https://psnet.ahrq.gov/issue/empowered-improve

1675. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33746/psn-pdf
      March 01, 2013 - medical school students, residents, or practicing physicians before they are deemed competent to do new techniques

1676. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps | PSNet
      psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
      April 24, 2018 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps Citation Text: Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy …

1677. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet
      psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
      October 27, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. Citation Text: Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format…

1678. Are We Pushing Graduate Nurses Too Fast? | PSNet
      psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
      November 16, 2022 - Are We Pushing Graduate Nurses Too Fast? Citation Text: Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3…

1679. The Forgotten Med | PSNet
      psnet.ahrq.gov/web-mm/forgotten-med
      July 01, 2006 - The Forgotten Med Citation Text: Cucina R. The Forgotten Med. 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 tagged PubMedId RIS …

1680. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49495/psn-pdf
      December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…