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Total Results: 1,064 records

Showing results for "ultimately".

101. The collapse of sensemaking in organizations: the Mann Gulch disaster. | PSNet
     psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
     May 21, 2019 - who improvised a response to a fire by setting a back-fire while the rest of his crew panicked and ultimately

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42063/psn-pdf
     January 06, 2018 - The authors critically examine the evidence supporting 41 separate PSPs and ultimately arrive at a list

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39389/psn-pdf
     January 03, 2017 - underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately

104. Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure. | PSNet
     psnet.ahrq.gov/issue/misdiagnosis-and-missed-diagnoses-foster-and-adopted-children-prenatal-alcohol-exposure
     June 27, 2018 - The vast majority of children ultimately determined to have fetal alcohol spectrum disorder in this cohort

105. Emergency department visits for antibiotic-associated adverse events. | PSNet
     psnet.ahrq.gov/issue/emergency-department-visits-antibiotic-associated-adverse-events
     October 31, 2014 - An ultimately fatal case of an antibiotic adverse drug event is discussed in an AHRQ WebM&M commentary

106. Creating the web-based intensive care unit safety reporting system.  | PSNet
     psnet.ahrq.gov/issue/creating-web-based-intensive-care-unit-safety-reporting-system
     October 13, 2018 - They discuss how reports are generated, collected, and ultimately disseminated back to frontline staff

107. Structural iatrogenesis—a 43-year-old man with "opioid misuse." | PSNet
     psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse
     September 04, 2016 - acetaminophen–hydrocodone for many years to experience job insecurity, withdrawal symptoms, and uncontrolled pain, which ultimately

108. Reducing in-hospital cardiac arrests and hospital mortality by introducing a medical emergency team. | PSNet
     psnet.ahrq.gov/issue/reducing-hospital-cardiac-arrests-and-hospital-mortality-introducing-medical-emergency-team
     March 11, 2013 - Rapid response systems function within a variety of structures, but they ultimately remain a mechanism

109. Workplace violence against anesthesiologists: we are not immune to this patient safety threat. | PSNet
     psnet.ahrq.gov/issue/workplace-violence-against-anesthesiologists-we-are-not-immune-patient-safety-threat
     March 06, 2005 - increased risk of burnout , burden on health care systems because of decreased retention in practice, and ultimately

110. Missed diagnoses of acute cardiac ischemia in the emergency department. | PSNet
     psnet.ahrq.gov/issue/missed-diagnoses-acute-cardiac-ischemia-emergency-department
     November 30, 2012 - Among patients ultimately diagnosed with acute myocardial infarction or unstable angina, approximately

111. Improving patient care. The cognitive psychology of missed diagnoses. | PSNet
     psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
     October 03, 2012 - events surrounding a series of diagnostic errors in a patient initially treated for pharyngitis and ultimately

112. CE/MOC Quizzes | PSNet
     psnet.ahrq.gov/cme
     February 26, 2025 - However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition … Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to

113. The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Monitoring. | PSNet
     psnet.ahrq.gov/issue/definition-quality-and-approaches-its-assessment-vol-1-explorations-quality-assessment-and
     May 24, 2015 - Quality and safety are ultimately determined by the degree to which health care improves important patient

114. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
     February 01, 2016 - The urologist persisted in using the robotic technology and ultimately was able to complete the procedure … The patient ultimately required several additional surgeries and a prolonged hospital stay. 6 Background … already complex and risk-fraught arena 24 Take-Home Points (2) In general, surgical outcomes are ultimately

115. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846127/psn-pdf
     March 15, 2023 - By the time this patient ultimately underwent surgical reassessment, his symptoms had worsened and he … The patient in this case ultimately developed septic complications and was admitted to the hospital for … may lead to lower readmission rates,7 better provider communication and patient satisfaction, and ultimately

116. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33726/psn-pdf
     March 01, 2012 - One of the early cases we tried was a case that ultimately I could have settled for $40,000 or $50,000 … Instead of seeing people as ultimately disposable, we're getting our arms around them and we're enrolling … Hold them accountable but protect them from draconian penalties if we want to protect ultimately our … Ultimately it's not about claims at all, it's about making people safer. … RB: I bristle at the headlines that say apology saves money because ultimately it's not about claims—it's

117. Transparent and open discussion of errors does not increase malpractice risk in trauma patients. | PSNet
     psnet.ahrq.gov/issue/transparent-and-open-discussion-errors-does-not-increase-malpractice-risk-trauma-patients
     October 19, 2022 - The authors discuss the clinical and legal information from selected malpractice suits but ultimately

118. Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice. | PSNet
     psnet.ahrq.gov/issue/patient-safety-incidents-associated-obesity-review-reports-national-patient-safety-agency-and
     October 19, 2022 - for patients with obesity are discussed in an AHRQ WebM&M commentary , which examined a case of an ultimately

119. The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit. | PSNet
     psnet.ahrq.gov/issue/impact-traditional-and-smart-pump-infusion-technology-nurse-medication-administration
     May 18, 2022 - Ultimately, creation of a " closed-loop " system that integrates technological solutions to prescription

120. Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students. | PSNet
     psnet.ahrq.gov/issue/innovative-patient-safety-curriculum-using-ipad-game-passed-improved-patient-safety-concepts
     November 16, 2022 - concepts, which was followed by a 20-minute lecture on patient safety, 20–30 minutes of the game, and ultimately