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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - may be on medications that could increase their risk of falls or bleeding, patients with indwelling central … venous or urinary catheters, or patients with similar names.
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - intraosseous (IO) line in the left tibia following several unsuccessful attempts to obtain peripheral venous … head is superior—up to five times
higher—to that in the tibial space, approaching the flow into a central
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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - patients with febrile neutropenia includes: (i) obtaining at least two sets of blood
cultures (if a central … venous catheter is present, a set should be collected from each lumen and from a
peripheral site),
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - On hospital day 4, the ICU team and the neurosurgeon decided it would be safe to start deep venous thrombosis … the patient with full-dose anticoagulation (rather than lower dose anticoagulation, appropriate for venous … A central hallmark of I-PASS and other high-quality handoff communication programs is the emphasis on
-
psnet.ahrq.gov/node/33793/psn-pdf
November 01, 2015 - some other widely recommended intervention like
with medication reconciliation, rapid response teams, central … The central line bundle is a wonderful thing that Peter Pronovost has
championed. … If you've implemented the central line bundle, then you should measure central
line–associated infections … If I want to know if something new has come out on venous thromboembolism, I can easily
create an automatic
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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - Appreciate that dizziness “plus” other neurological symptoms is more likely to be caused by a central … They are often due to pathology of the peripheral vestibular apparatus or its central connections. … syndrome, hypercoagulable states and others.11
Young patients with cardioembolic strokes often have venous … Direction-changing nystagmus is always central. … cannot walk independently, they should be evaluated for stroke or other central causes.
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Her undergraduate nursing degree was obtained in 1989 from the University of Central Missouri. … obstetrics, hospital-associated infections, emergency departments, sepsis, falls, pressure ulcers, venous … on surgical patient safety, infusion safety, clinical alarms safety, unit-based safety improvement, venous
-
psnet.ahrq.gov/node/33741/psn-pdf
November 01, 2012 - The venous pulsations in the patient's neck indicate
the diagnosis is constrictive pericarditis, a disorder … Bedside differentiation of vestibular neuritis
from central "vestibular pseudoneuritis."
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psnet.ahrq.gov/web-mm/chemotherapy-extravasation
September 24, 2010 - relatively new to the job had difficulty placing a peripheral IV catheter but was ultimately able to achieve venous … Refer patients at high risk for peripheral extravasation for central line placement. … January 4, 2012
WebM&M Cases
Central, not Epidural
-
psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - swiss-cheese-model
https://psnet.ahrq.gov//#1
anesthesiologist placed devices on the skin and inserted a central … venous line for monitoring. … sponges
Provide packages of
sharps or sponges
without shared
information to nurses
After inserting a central … radiography
Poor image
transmission
On the postoperative chest x-ray taken to check the
position of the central
-
psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - Appreciate that dizziness “plus” other neurological symptoms is more likely to be caused by a central … They are often due to pathology of the peripheral vestibular apparatus or its central connections. … syndrome, hypercoagulable states and others. 11 Young patients with cardioembolic strokes often have venous … Direction-changing nystagmus is always central. … cannot walk independently, they should be evaluated for stroke or other central causes.
-
psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - Appreciate that dizziness “plus” other neurological symptoms is more likely to be caused by a central … They are often due to pathology of the peripheral vestibular apparatus or its central connections. … syndrome,
hypercoagulable states and others.11
Young patients with cardioembolic strokes often have venous … Direction-changing nystagmus is always central. … cannot walk independently, they should be evaluated for stroke or
other central causes.
-
psnet.ahrq.gov/node/33701/psn-pdf
October 01, 2010 - in
deaths and complications (3) and a checklist guiding the activities surrounding the insertion of central … venous catheters that reduced bloodstream infections up to 66% in approximately 100 Michigan intensive
-
psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - These include
compliance with hand hygiene, optimal management of central venous and urinary catheters
-
psnet.ahrq.gov/web-mm/saved-ecmo
May 05, 2017 - Arterial and central venous lines could have been placed prior to the epidural and the cardiac surgery
-
psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - Call: Addressing Errors From Previous Providers
March 1, 2014
Elimination of central-venous-catheter-related
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - patient that night called the attending physician and asked for permission for peripheral intravenous central … venous catheter (PICC) placement.
-
psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - During the case, the anesthesiologist placed devices on the skin and inserted a central venous line for … sponges Provide packages of sharps or sponges without shared information to nurses After inserting a central … radiography Poor image transmission On the postoperative chest x-ray taken to check the position of the central
-
psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - So, staff that were used to a certain type of central line care kit, for example, now had to use something … And even standard care, like catheter care and central line care, was changed dramatically for a person … How do you monitor the central line site? Many aspects of patient safety had to be adapted. … venous catheter use increased during the pandemic 6 , 9 and that COVID-19 patients are at a higher … Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI),
-
psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - venous catheter use increased during the pandemic 6 , 9 and that COVID-19 patients are at a higher … hospitalization of COVID-19 patients, but also to challenges in maintaining those devices (catheters, central … Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), … And even standard care, like catheter care and central line care, was changed dramatically for a person … How do you monitor the central line site? Many aspects of patient safety had to be adapted.