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8741. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

8742. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion | PSNet
      psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
      June 14, 2023 - Another potential educational tool is to create a realistic simulation on medication administration errors

8743. Patient and Family Roles in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-and-family-roles-safety
      June 14, 2023 - A practical, insightful recommendation from advisors—a succinct, clear, practical tool that tells a person

8744. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
      June 14, 2023 - A practical, insightful recommendation from advisors—a succinct, clear, practical tool that tells a person

8745. The "Customer" Is Always Right | PSNet
      psnet.ahrq.gov/web-mm/customer-always-right
      January 22, 2014 - July 2, 2014 I-CaRe: a case review tool focused on improving inpatient care.

8746. Thin Air | PSNet
      psnet.ahrq.gov/web-mm/thin-air
      March 01, 2006 - cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool

8747. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33738/psn-pdf
      December 01, 2012 - JR: There was a recommendation to create what I call a matrix, a quality functional deployment tool,

8748. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33744/psn-pdf
      February 01, 2013 - This tool is preventing errors in the hospital, and by the time patients and families are ready to go

8749. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33674/psn-pdf
      February 01, 2009 - When hospitals can reach into a tool kit and with good evidence know they have to do these five things

8750. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
      January 01, 2024 - The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners.

8751. Dangerous Shift | PSNet
      psnet.ahrq.gov/web-mm/dangerous-shift
      July 24, 2013 - The SBAR example is based upon the worksheet tool provided by the Institute for Healthcare Improvement

8752. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49729/psn-pdf
      April 01, 2015 - Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification

8753. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49870/psn-pdf
      August 10, 2019 - Colonoscopies are a useful screening tool (with an estimated sensitivity of 75% to 93% for adenomas

8754. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks | PSNet
      psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
      September 01, 2017 - Author(s) WebM&M Cases Failed Interpretation of Screening Tool

8755. Failure to Report | PSNet
      psnet.ahrq.gov/web-mm/failure-report
      July 01, 2008 - One tool drawn from crew teamwork training in aviation is self-critiquing, a team activity that involves

8756. Elopement | PSNet
      psnet.ahrq.gov/web-mm/elopement
      July 14, 2010 - improve safety.( 8 ) Such an assessment and possible precautions have been outlined in an elopement tool

8757. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50699/psn-pdf
      November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019 Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients Background Older patients are at a particular risk of experiencing a patient safety event. Stud…

8758. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50610/psn-pdf
      October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit October 30, 2019 Profit J, Scheid A, Ridout E. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safe…

8759. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49743/psn-pdf
      September 01, 2015 - Dual Therapy Debacle September 1, 2015 Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dual-therapy-debacle The Case An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long history of tobacco use …

8760. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49766/psn-pdf
      August 21, 2016 - Getting the (Right) Doctor, Right Away August 21, 2016 Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away The Case A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery. Postop…