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Total Results: 2,437 records

Showing results for "thinking".

2301. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet
      psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
      March 18, 2020 - November 2, 2011 Perspective Establishing a Safety Culture: Thinking

2302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867427/psn-pdf
      December 18, 2024 - The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls Falls are not a new issue, especially among older adults. The Centers for D…

2303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33848/psn-pdf
      December 01, 2017 - The Evolution of Patient Safety in Surgery December 1, 2017 Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery Perspective In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…

2304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49488/psn-pdf
      August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…

2305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33844/psn-pdf
      October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient Safety October 1, 2017 Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety Perspective Introduction Health care–as…

2306. Accountability in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/accountability-patient-safety
      January 01, 2018 - Annual Perspective Accountability in Patient Safety Christopher Moriates, MD, and Robert M. Wachter, MD | January 1, 2015  View more articles from the same authors. Citation Text: Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. Rock…

2307. Dying in the Hospital With Advanced Dementia | PSNet
      psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
      November 01, 2016 - The family had thought their doctor had been informed of their mother's death and assumed that the PCP … This case illustrates the fallacy of this thinking.

2308. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer | PSNet
      psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
      February 26, 2025 - Engage just culture principles and transform thinking from a root-cause analysis framework to a systems-focused

2309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851389/psn-pdf
      July 31, 2023 - Engage just culture principles and transform thinking from a root-cause analysis framework to a systems-focused

2310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49769/psn-pdf
      September 01, 2016 - The nurse thought it unusual to increase the pain medication so much, but she remembered that this hospitalist

2311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50927/psn-pdf
      February 21, 2020 - Patient Safety in Primary Care February 21, 2020 Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/patient-safety-primary-care Introduction A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare …

2312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49703/psn-pdf
      March 01, 2014 - After-Visit Confusion March 1, 2014 Ventres W. After-Visit Confusion. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/after-visit-confusion The Case An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white spots near her tongue. The patient's mother accompanied her …

2313. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49392/psn-pdf
      April 01, 2003 - Risk factors can be thought of as being intrinsic (eg, leg weakness, poor balance, cognitive impairment … The nurses identified him as being at “very high risk” for falls and thought the patient should be placed … Two final thoughts occur to me as I review this case.

2314. Another Fall | PSNet
      psnet.ahrq.gov/web-mm/another-fall
      June 01, 2010 - Risk factors can be thought of as being intrinsic (eg, leg weakness, poor balance, cognitive impairment … The nurses identified him as being at “very high risk” for falls and thought the patient should be placed … Two final thoughts occur to me as I review this case.

2315. Consequences of Medical Overuse | PSNet
      psnet.ahrq.gov/web-mm/consequences-medical-overuse
      May 05, 2021 - Decreasing the amount of overuse will require better education of clinicians in probabilistic thinking

2316. Delayed Breast Cancer Diagnosis: A False Sense of Security. | PSNet
      psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
      May 01, 2005 - Thinking, Fast and Slow. New York: Farrar, Straus and Giroux; 2011.

2317. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49389/psn-pdf
      February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…

2318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850362/psn-pdf
      June 14, 2023 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital June 14, 2023 Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…

2319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73412/psn-pdf
      August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) June 30, 2021 https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and- disclosure Summary The Behavioral Health Vital Signs (BHVS) screener i…

2320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49473/psn-pdf
      March 01, 2005 - On O.R. Off? March 1, 2005 Leonard M. On O.R. Off? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/or The Case An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting …