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psnet.ahrq.gov/node/49666/psn-pdf
October 01, 2012 - IDSA MRSA guidelines state, "For simple abscesses or
boils, incision and drainage alone is likely adequate … administrators and coaches should provide facilities and
equipment necessary to promote good hygiene, such as adequate … Establish routine cleaning schedule of shared equipment; ensure availability of adequate cleaning
supplies
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psnet.ahrq.gov/issue/systems-errors-versus-physicians-errors-finding-balance-medical-education
October 12, 2012 - hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate
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psnet.ahrq.gov/issue/results-national-neurosurgery-resident-survey-duty-hour-regulations
September 29, 2017 - hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate
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psnet.ahrq.gov/issue/restricted-duty-hours-surgeons-and-impact-residents-quality-life-education-and-patient-care
October 08, 2008 - hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate
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psnet.ahrq.gov/issue/resident-duty-hours-and-medical-education-policy-raising-evidence-bar
August 20, 2018 - hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate
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psnet.ahrq.gov/issue/fatigue-risk-management-impact-anesthesiology-residents-work-schedules-job-performance-and
November 03, 2010 - hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate
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psnet.ahrq.gov/issue/ethical-considerations-development-flexibility-duty-hour-requirements-surgical-trainees-trial
June 21, 2017 - hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate
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psnet.ahrq.gov/node/865309/psn-pdf
May 29, 2024 - mucosa in the upper airway, which is responsible for
heating and humidifying inhaled air.2 As a result, adequate … low quality of evidence, patients
must meet several parameters to use an HME effectively, including adequate … first 48 hours.4 Monitoring for these
complications in the early postoperative period, while providing adequate
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - the area that I know best, primary care, substantial questions must be asked about whether we have adequate … So we have to think about whether our staffing is adequate in certain areas, and whether primary care … It first focused on hepatitis C and trying to support rural primary care providers who did not have adequate
-
psnet.ahrq.gov/node/49452/psn-pdf
July 01, 2004 - Adequate communication, identity verification, and teamwork seem lacking. … workers.(17) To succeed in actively
engaging patients in their own care and error prevention mandates adequate
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psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
June 01, 2010 - Financial and workforce constraints may drive ED staffing to levels that, while adequate for average … ED volumes, are not adequate for higher volume days. … (i) Nurse and physician staffing should build in adequate buffers for high-volume periods, so that delays … (iii) Noise and interruptions should be minimized by provision of adequate security and provider assistants … Admission-observation of high-risk patients
Medical home for patients with chronic illness
Adequate
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - Liberal use of local or regional anesthesia facilitates adequate exploration. … algorithms, checklists, and visual aids. 16 While a checklist or visual aid is never a substitute for adequate … Optimizing working conditions is critical to patient safety, and in this case may include adequate clinician
-
psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Other ways of ensuring adequate communication and counseling include:6
Simplifying the language used … Adequate
patient/caregiver counseling in both cases may have prevented these medication discrepancies … In Case 2, adequate discharge counseling, using
the teach-back method with the patient and his daughter
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - air leak around the tracheostomy cuff; additional
inflation of the cuff was required to obtain an adequate … An oral endotracheal tube was placed with the balloon distal to the tracheal
injury and adequate ventilation … mechanical ventilation require a tracheostomy tube that has an appropriate internal
diameter to achieve adequate
-
psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - Allow adequate time for pre-op assessment
Turnover times in operating and procedure rooms are keenly … A nerve stimulator could have been used to verify
adequate recovery of neuromuscular function prior … Sufficient time needs to be allocated for an adequate preoperative evaluation.
-
psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - This approach was not adequate and led to continued postoperative bleeding and eventual death from untreated … useful because it gives the surgeon time to get assistance, to clear the operative field, to achieve adequate … blood cells to platelets as best practice established in the PROPPR trial. 12 In addition to assuring adequate
-
psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - left suprahilar region” was attributed to a probable artifact, some
radiologists would consider it adequate … between the patient and the radiologist
25
TAKE HOME POINTS
26
Take-Home Points
27
• Timely and adequate
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - placed on night shift
– Hospitals must ensure that new graduates and nurses with less
experience have adequate … supervision and mentoring
– This requires both appropriate staffing levels with adequate
numbers of
-
psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - products/safeplaceed/
Successful Prevention
Overarching goal is safe patient care
Must link adequate