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Total Results: 1,064 records

Showing results for "ultimately".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865413/psn-pdf
    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 … And ultimately, when hospitals are attacked with ransomware, lives are threatened, and we need to plan

  2. Root Cause Analysis | PSNet

    psnet.ahrq.gov/primer/root-cause-analysis
    March 30, 2022 - The patient ultimately died of hypovolemic shock.  

  3. Diagnostic Errors Case Studies | PSNet

    psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
    May 05, 2025 - The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably … The patient ultimately presented to the emergency department with a bowel obstruction, was diagnosed

  4. 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…

  5. 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…

  6. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
    December 01, 2007 - .): Elopement Ultimately, the patient was found outside the emergency department, with ED discharge … Ultimately the patient was found outside of the emergency department, with ED Discharge Instructions

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33681/psn-pdf
    March 01, 2009 - improve consumer information materials, such as prescription drug labeling, to promote comprehension and ultimately … more easily obtain, process, and understand health information to be able to make informed decisions ultimately

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33647/psn-pdf
    March 01, 2007 - Terrified and in restraints, she ultimately managed to self-extubate and clear her breathing passage.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49860/psn-pdf
    April 01, 2019 - 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

  10. An Outpatient 'Zebra' | PSNet

    psnet.ahrq.gov/web-mm/outpatient-zebra
    January 23, 2020 - The patient ultimately received a diagnosis of left superficial femoral artery occlusion and underwent … Fortunately, the patient ultimately received the correct diagnosis and therapy with a desirable outcome

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34871/psn-pdf
    February 09, 2011 - Educational levels of hospital nurses and surgical patient mortality. February 9, 2011 Aiken LH, Clarke S, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617-1623. https://psnet.ahrq.gov/issue/educational-levels-hospital-nurses-and-surgical-patient-morta…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861764/psn-pdf
    January 31, 2024 - Low rate of completion of recommended tests and referrals in an academic primary care practice with resident trainees. January 31, 2024 Amat MJ, Anderson TS, Shafiq U, et al. Low rate of completion of recommended tests and referrals in an academic primary care practice with resident trainees. Jt Comm J Qual Patien…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40321/psn-pdf
    March 30, 2011 - Inaccuracies in assignment of clinical stage for localized prostate cancer. March 30, 2011 Reese AC, Sadetsky N, Carroll PR, et al. Inaccuracies in assignment of clinical stage for localized prostate cancer. Cancer. 2011;117(2):283-9. doi:10.1002/cncr.25596. https://psnet.ahrq.gov/issue/inaccuracies-assignment-cli…

  14. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - • The Joint Commission requires annual drills to identify areas of improvement and success, ultimately … • Regular obstetric simulations can improve team communication, processes and collaboration, ultimately

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866584/psn-pdf
    August 28, 2024 - Raising the barcode: improving medication safety behaviours through a behavioural science-informed feedback intervention. A quality improvement project and difference-in-difference analysis. August 28, 2024 Grailey K, Brazier A, Franklin BD, et al. Raising the barcode: improving medication safety behaviours throu…
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