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Total Results: 1,018 records

Showing results for "ultimately".

161. Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
     January 01, 2024 - • The patient ultimately died of multiple organ failure. 7 DELAYED DIAGNOSIS AND TREATMENT OF … DIAGNOSISING PSYCHOTIC ILLNESS 12 Diagnosing Psychotic Illness (1) • Psychotic illness that is ultimately

162. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
     psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
     December 23, 2020 - The errors led to considerable soul searching and, ultimately, a major change in institutional practices

163. In Conversation With… Mark L. Graber, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
     January 01, 2016 - You and colleagues began to chart a strategy to get this on the radar screen, and ultimately that led … Then, ultimately I see the Institute of Medicine getting involved. How did that all happen? … We will ultimately get to decision support and medical record systems that really do improve diagnosis … But in some ways the promise held out over the last 30 years was ultimately that we wouldn't need the … While researchers tackle and, ultimately, solve these complex issues, it will be a huge leap forward

164. Code Blue—Where To? | PSNet
     psnet.ahrq.gov/web-mm/code-blue-where
     March 30, 2020 - The Commentary Although it was ultimately discovered that this patient did not want resuscitation, … While "best" strategy depends ultimately on the hospital's resources, we think the best solution is properly

165. Breathe Easy: Safe Tracheostomy Management | PSNet
     psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
     June 07, 2023 - Multiple unsuccessful attempts were made and the patient ultimately went into cardiac arrest. … Fortunately in the case presented, this recommended practice was ultimately followed to avert further

166. Charcoal Lavage of the Lungs | PSNet
     psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
     January 01, 2016 - quite toxic to the lungs), but he developed multiple complications including progressive pneumonia and ultimately … Ultimately, these are problems of knowledge, training, and credentialing, but they can also be addressed

167. Informed or Misled? | PSNet
     psnet.ahrq.gov/web-mm/informed-or-misled
     April 24, 2018 - For unclear reasons, the patient ultimately received general anesthesia and suffered the adverse outcome … Patients may ultimately require a period of reflection, either alone or in conversation with their families

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851158/psn-pdf
     June 28, 2023 - Although the primary operator is ultimately responsible for the patient, each team member must be involved … Ultimately, this case is an excellent example of what can happen when best practices are not followed

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74242/psn-pdf
     January 07, 2022 - medical errors.10,11 These medical pre-procedure checklists should be able to be utilized by anyone but ultimately … checklists should be confirmed as complete by the nurse, the physician directly caring for the patient, and ultimately

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42009/psn-pdf
     December 19, 2018 - Charting the Course: Launching Patient-Centric Healthcare. December 19, 2018 Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128. https://psnet.ahrq.gov/issue/charting-course-launching-patient-centric-healthcare This book builds on concepts explored in Why Hospitals Shou…

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33612/psn-pdf
     May 01, 2005 - The errors led to considerable soul searching and, ultimately, a major change in institutional practices

172. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement | PSNet
     psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
     July 01, 2004 - He ultimately underwent surgery and was discharged to home a few days later. … After discussion with his family, the patient was ultimately transitioned to hospice and died several

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867436/psn-pdf
     January 08, 2025 - The role of AI in detecting and mitigating human errors in safety-critical industries: a review. January 8, 2025 Gursel E, Madadi M, Coble JB, et al. The role of AI in detecting and mitigating human errors in safety- critical industries: a review. Reliability Eng System Saf. 2025;256:110682. doi:10.1016/j.ress.2024…

174. When the Meds Don’t Reach the Bed | PSNet
     psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
     May 16, 2022 - Ultimately, these failures led to an avoidable readmission. … a review; clarifying the goals of care with the patient and his family during the second admission ultimately … Recommendations Ultimately, the discharge process is too complex to expect that any single intervention

175. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
     psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
     January 01, 2016 - While researchers tackle and, ultimately, solve these complex issues, it will be a huge leap forward … You and colleagues began to chart a strategy to get this on the radar screen, and ultimately that led … Then, ultimately I see the Institute of Medicine getting involved. How did that all happen? … We will ultimately get to decision support and medical record systems that really do improve diagnosis … But in some ways the promise held out over the last 30 years was ultimately that we wouldn't need the

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47970/psn-pdf
     May 01, 2019 - Can we import improvements from industry to healthcare? May 1, 2019 Macrae C, Stewart K. Can we import improvements from industry to healthcare? BMJ. 2019;364:l1039. doi:10.1136/bmj.l1039. https://psnet.ahrq.gov/issue/can-we-import-improvements-industry-healthcare Principles from high-risk industries can be appli…

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33576/psn-pdf
     December 15, 2024 - Ultimately, preventing WSPEs depends on the combination of system solutions, strong teamwork and safety

178. Do Not Miss Sepsis Needles in Viral Haystacks! | PSNet
     psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
     March 27, 2024 - a failure to identify sepsis in a pediatric patient, leading to the development of septic shock and ultimately … into thinking that sepsis follows a clear continuum from SIRS to sepsis, followed by severe sepsis and ultimately … Ultimately, the goal of early sepsis recognition is the rapid implementation of appropriate treatment

179. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49547/psn-pdf
     October 01, 2007 - The Commentary Although it was ultimately discovered that this patient did not want resuscitation, many … While "best" strategy depends ultimately on the hospital's resources, we think the best solution is

180. In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity | PSNet
     psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
     March 27, 2024 - Ultimately, you have an attack, and suddenly incident command is triggered. … Mostly your building systems may be on, but ultimately, all the technology that you normally relied on … And ultimately, when hospitals are attacked with ransomware, lives are threatened, and we need to plan … for, respond to, and recover from cyberattacks much more quickly and effectively in the future and, ultimately