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Total Results: 4,259 records

Showing results for "wrong".

  1. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience | PSNet

    psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
    July 20, 2010 - This is truly unfortunate, since it is both wrong and short sighted: the lessons learned from catastrophic

  2. Discharged Blindly | PSNet

    psnet.ahrq.gov/web-mm/discharged-blindly
    October 26, 2022 - October 1, 2008 WebM&M Cases Wrong Route for Nutrients

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867655/psn-pdf
    February 26, 2025 - strong safety culture make it possible to communicate openly, learn from what went well and what went wrong

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - at a dose of 0.4 units/minute ICU fellow overhears this and realizes the patient is receiving the wrong

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
    December 01, 2004 - health problems and complications to watch for Know the follow-up plan and who to call if things go wrong

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33797/psn-pdf
    January 01, 2016 - For example, diagnoses can be completely missed (cancer missed despite alarming symptoms), wrong (patients

  7. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
    May 01, 2018 - She logged into the medical record of one of these patients—the wrong one—and saw a normal CRP value,

  8. The Forgotten Drip | PSNet

    psnet.ahrq.gov/web-mm/forgotten-drip
    April 01, 2014 - WebM&M Cases Getting the Diagnosis Both Right and Wrong

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33638/psn-pdf
    August 01, 2006 - In fact, most of the discussions were about all of the other kinds of things that can go wrong.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49574/psn-pdf
    November 01, 2008 - The confused intern chose the wrong form, causing the patient to receive insulin in doses that failed

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - accident trajectories, identify decisions that may have been ambiguous (at best) in real time as clearly wrong

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33821/psn-pdf
    December 01, 2016 - approach is to learn from minor errors and near-miss incidents, such as when a doctor records the wrong

  13. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
    January 01, 2020 - From possible to probable to sure to wrong—premature closure and anchoring in a complicated case.

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33808/psn-pdf
    May 01, 2016 - seemed logical to build in alarms and alerts to let clinicians know when something is—or might be—wrong

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49740/psn-pdf
    August 21, 2015 - Secondary loss of clinical responses to botulinum neurotoxin injections are more likely to be due to wrong

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33640/psn-pdf
    September 01, 2006 - include increasing disclosure of adverse events; root cause analyses; and programs for preventing falls, wrong-site

  17. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.ppt
    July 01, 2008 - What Went Wrong Patient’s worsening in the face of opioid agonist therapy should have triggered the

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49414/psn-pdf
    September 01, 2003 - If the wrong insufflator were used, the patient could have received greater than ten times the normal

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49850/psn-pdf
    January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…

  20. 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 - February 1, 2013 WebM&M Cases Right Regimen, Wrong
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