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psnet.ahrq.gov/node/49746/psn-pdf
October 01, 2015 - The patient had a prolonged postoperative course with intra-abdominal infection before ultimately dying … Ultimately, if the process goes uninterrupted, death
may result, from either septic or hypovolemic shock
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The patient missed this follow-up appointment and ultimately returned to the clinic several months later … The patient was ultimately diagnosed with
primary lung adenocarcinoma involving the right upper lung
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - Given that her new presentation included fever, blood cultures were drawn, ultimately growing yeast. … to dialysis and receipt of pain treatment with IV opiates led to
problems with vascular access and ultimately
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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - 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
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - Ultimately, the chosen empiric antibiotic did not match the susceptibility of the bacterial pathogen. … psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Ultimately
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - Some of those systems ultimately became training centers for TeamSTEPPS and
shared their experiences … Stephen Hines: Ultimately, the value of TeamSTEPPS is not in the curriculum itself, but in how people … The revisions aim to make it easier for people to get value out of TeamSTEPPS, but ultimately, it
is
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psnet.ahrq.gov/node/50914/psn-pdf
February 19, 2020 - Uncovering, creating or constructing problems? Enacting
a new role to support staff who raise concerns about
quality and safety in the English National Health Service
February 19, 2020
Martin GP, Chew S, Dixon-Woods M. Uncovering, creating or constructing problems? Enacting a new role
to support staff who raise co…
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psnet.ahrq.gov/node/34707/psn-pdf
September 29, 2017 - National Patient Safety Foundation agenda for research
and development in patient safety.
September 29, 2017
Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and
development in patient safety. MedGenMed. 2000;2(3):E38.
https://psnet.ahrq.gov/issue/national-patient-safe…
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psnet.ahrq.gov/node/35392/psn-pdf
June 16, 2011 - Measuring patient safety climate: a review of surveys.
June 16, 2011
Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety climate: a review of surveys. Qual Saf
Health Care. 2005;14(5):364-6.
https://psnet.ahrq.gov/issue/measuring-patient-safety-climate-review-surveys
This systematic review compares th…
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - 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. … In general, surgical outcomes are ultimately a direct manifestation of the skill and experience of the
-
psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - Ultimately, the truth comes out. … from medical mistakes in the United States were the equivalent of a jumbo jet crashing every day—to ultimately … and other conferences), all of which increase the chances that errors will see the light of day, and ultimately … Led to New York law regarding supervision and work hours, and ultimately ACGME duty hours regulations … leg amputated
University Community Hospital, Tampa, FL
1995
New focus on wrong-site surgery, ultimately
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - from medical mistakes in the United States were the equivalent of a jumbo jet crashing every day—to ultimately … and other conferences), all of which increase the chances that errors will see the light of day, and ultimately … Led to New York law regarding supervision and work hours, and ultimately ACGME duty hours regulations … leg amputated
University Community Hospital, Tampa, FL
1995
New focus on wrong-site surgery, ultimately … Ultimately, the truth comes out.
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - if you can show that by doing some little things to help them take care of themselves better, then ultimately … Ultimately, I think that's a big part of what we're doing, relabeling what needs to be addressed in some … additional looks at why those projects worked and why they have been relatively hard to replicate, I think ultimately
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psnet.ahrq.gov/node/39985/psn-pdf
November 10, 2010 - Establishing a global learning community for incident-
reporting systems.
November 10, 2010
Pham JC, Gianci S, Battles J, et al. Establishing a global learning community for incident-reporting
systems. Qual Saf Health Care. 2010;19(5):446-51. doi:10.1136/qshc.2009.037739.
https://psnet.ahrq.gov/issue/establishing-…
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - early, enabling them
to receive timely, targeted interventions that can prevent suicide attempts and ultimately … to these guidelines ensure that every screening
session is an opportunity for early intervention, ultimately
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psnet.ahrq.gov/continuing-education
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
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - 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
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - patient safety as well as how the COVID-19 pandemic affected partnership with patients and families, ultimately … patient safety as well as how the COVID-19 pandemic affected partnership with patients and families, ultimately
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psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
August 01, 2015 - NS : Ultimately do you come away from it feeling more optimistic about the role health information technology … RW : The hope is that ultimately the computer frees up time, and it does that in the same way that it … What do you think will ultimately be different in 10 years compared to where we are now? … little bit more disappointed in today's current state because I have a better sense of where we can ultimately
-
psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - NS : Ultimately do you come away from it feeling more optimistic about the role health information technology … RW : The hope is that ultimately the computer frees up time, and it does that in the same way that it … What do you think will ultimately be different in 10 years compared to where we are now? … little bit more disappointed in today's current state because I have a better sense of where we can ultimately