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2901. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet
      psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
      July 23, 2024 - Therefore, adoption in clinical settings remains challenging. 7 Additionally, evidence suggests that … formed a multidisciplinary workgroup to perform an evidence review on RSIs and identify evidence-based guidelines … Two common themes and findings that emerged from the workgroup review were (1) intraorganizational guidelines … The chief clinical officer (CCO) plays a pivotal role in guiding the implementation, with assistance

2902. Patient Safety: A Perspective from Office Practice | PSNet
      psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
      May 01, 2009 - Patient Safety: A Perspective from Office Practice Richard J. … Patient Safety: A Perspective from Office Practice. PSNet [internet]. … the proper context, as the root cause of many potential unhappy outcomes—far more so than our lack of clinical … argued that physicians' learned helplessness training begins early in residency, where we divide up "clinical … Physicians can make very persuasive clinical arguments but not very persuasive financial ones, because

2903. Retained Surgical Items: Definition and Epidemiology. | PSNet
      psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
      September 15, 2024 - Background Prudent medical practice and federal and state laws require that any surgical item not intended … Coding Clinic, and thus the Centers for Medicare & Medicaid Services (CMS) follow the NQF SRE 2011 guidelines … follow the NQF definition for ICD-10-CM (International Classification of Diseases, 10 th Revision, Clinical … These items are unretrieved because a clinical determination has been made by the provider that the risk … These observations suggest that there are opportunities for practice improvements in the environments

2904. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet
      psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
      January 29, 2021 - anesthesia practice. … Christian Bohringer, MBBS Professor of Clinical Anesthesiology Department of Anesthesiology and Pain … Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in in daily clinical … practice: a cohort study of 188,064 patients registered in the Danish Anesthesia Database. … Operating Room April 27, 2022 Increased adherence to perioperative safety guidelines

2905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49413/psn-pdf
      September 01, 2003 - While the practice of sponge counts is a time-honored, simple preventive measure, it is heavily dependent … Changes to surgical practice and behavior also appear indicated, and new opportunities for technological … Bar-coding or impregnating sponges with detectable sensors would be new ways to improve an old practice … In: 2000 standards, recommended practices and guidelines: with official AORN statements. 1st ed.

2906. Duty to Disclose Someone Else's Error? | PSNet
      psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
      June 01, 2004 - First, important standards and guidelines have been developed by organizations such as the National Quality … 1900 US physicians, 17% had direct personal knowledge of a physician colleague who is incompetent to practice … One can imagine clinical situations in which the rationale for mandatory disclosure of another health … Respectful Management of Serious Clinical Adverse Events. … Talking with Patients and Families about Medical Error: A Guide for Education and Practice.

2907. In Conversation With… Richard Platt, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
      October 01, 2016 - We've been able to piggyback on that to answer questions that can inform system-level policy and practice … It used to require surveillance personnel to identify ventilator-associated pneumonia by reviewing clinical … Yet clinical data is complex and contextual—a heart rate may be listed under the formal vital sign table … Did clinicians at my institution transfuse blood in a way consistent with modern guidelines? … With a foot in both the clinical and data science realms, clinician data scientists are best positioned

2908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49835/psn-pdf
      January 01, 2020 - His nephrologist understood the guidelines for patients with chronic kidney disease (13) but was not … options for their patients.(17) Hospitalist services are studying and refining the application of these guidelines

2909. A Real Heartache | PSNet
      psnet.ahrq.gov/web-mm/real-heartache
      October 01, 2018 - Polevoi, MD Clinical Professor of Emergency Medicine Medical Director, Emergency Department … Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. … ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial … Perspective The Evidence-Based Physical Examination as a Patient Safety Practice … March 19, 2018 Implementation of the I-PASS handoff program in diverse clinical environments

2910. Sick and Pregnant | PSNet
      psnet.ahrq.gov/web-mm/sick-and-pregnant
      August 25, 2021 - categories and instead require that product labels include three main components: a fetal risk summary, clinical … All health care providers (physicians, pharmacists, nurses, dentists, etc.) should develop the practice … Shareen El-Ibiary, PharmD, BCPS Associate Professor of Clinical Pharmacy University of California … September 27, 2023 Handling injectable medications in anaesthesia: Guidelines from the … Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical

2911. Premature Closure: Was It Just Syncope? | PSNet
      psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
      February 10, 2021 - One of the first studies of medical checklists involved the World Health Organization’s (WHO) Guidelines … Journal of Clinical Neuroscience . 2015;22:1959-1962. Levis J. … Monitor Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Practice … Cognitive forcing strategies in clinical decisionmaking. … Assessment of a Best Practice Alert and Referral Process for Preprocedure Antithrombotic Medication Management

2912. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
      psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
      March 15, 2023 - Some institutions have adopted the practice of placing tracheostomy tubes with a distal extension, which … be structured in different ways and often include pulmonary and otolaryngology physicians, advanced practice … Elizabeth Gould, MSN, NP-C, CORLN ENT and Tracheostomy Advance Practice Specialist Nurse UC Davis Health … AARC clinical practice guideline: management of adult patients with tracheostomy in the acute care setting … December 3, 2008 Assessing diagnostic reasoning: a consensus statement summarizing theory, practice

2913. Weighing In on Surgical Safety | PSNet
      psnet.ahrq.gov/web-mm/weighing-surgical-safety
      August 04, 2021 - back and knee osteoarthritis, which severely limits physical activity and makes most forms of simple, clinical … There are existing practice guidelines that assist providers in managing perioperative glycemic control … achieved with the operating room table in the reverse Trendelenburg position.( 12 ) Therefore, our practice … anesthesia and surgical care provider will see more and more extremely obese patients in their daily practice … The morbidly obese patient presents a complex clinical challenge, and continuous ongoing medical education

2914. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49392/psn-pdf
      April 01, 2003 - usually determined by expert testimony) is that the patient, when taking into account all relevant clinical … Position Statement: Guidelines for Restraint Use. 1991. [ go to related site ] 2. JCAHO. … Physical restraints in the practice of medicine: current concepts. … A clinical trial to reduce restraints in nursing homes.

2915. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? | PSNet
      psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
      April 27, 2022 - States have varying staffing requirements and guidelines. … It would have been a best practice if the administrator had notified the nurse on call or the resident … Ron Ordona, DNP, FNP-BC, GS-C, WCC Health Sciences Assistant Clinical Professor Betty Irene Moore School … Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN Co-Editor-in-Chief, AHRQ’s Patient Safety Network (PSNet) Clinical … On-Call Geriatric Psychiatry: Handbook of Principles and Practice.

2916. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. | PSNet
      psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
      January 29, 2021 - Christian Bohringer, MBBS Professor of Clinical Anesthesiology Department of Anesthesiology and Pain … Non-alcoholic fatty liver disease and obesity: biochemical, metabolic and clinical presentations. … Best practice in stabilisation of oral endotracheal tubes: a systematic review. … Free full text ] Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists Practice … Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society

2917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33735/psn-pdf
      August 01, 2012 - Unanticipated safety risks continue to emerge (10), and recent guidelines advise that these agents be … decision support systems that incorporate relevant clinical information. … Although computerized provider order entry with clinical decision support has been shown to improve … Computerized clinical decision support during medication ordering for long-term care residents with … Effect of computerized provider order entry with clinical decision support on adverse drug events in

2918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49741/psn-pdf
      September 01, 2015 - in the differential and the presence of bands are abnormal and require further investigation.(8) If clinical … The use of the algorithm as well as the clinical outcomes of pregnant patients with abdominal pain should … ACOG Committee on Obstetric Practice. … ACOG Committee Opinion #299 (replaces #158, September 1995): guidelines for diagnostic imaging during … Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs.

2919. Charcoal Lavage of the Lungs | PSNet
      psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
      January 01, 2016 - However, the best check of NG tube placement is chest x-ray; x-ray is standard practice in narrow-bore … problems of knowledge, training, and credentialing, but they can also be addressed in part by protocols or guidelines … Clinical procedures in emergency medicine. 2nd ed. Philadelphia: WB Saunders; 1991. 4.

2920. WebM&M: Case Studies | PSNet
      psnet.ahrq.gov/webmm-case-studies
      March 25, 2025 - Improvement (2) Critical Pathways (31) Patient Self-Management (10) Practice … Guidelines (112) Reminders (12) Specialization of Care (56) … Clinical Pharmacist Involvement (25) Hospitalists (4) Intensivists and Other … The commentary provides an overview of the clinical manifestations of intraoperative durotomy, intra- … information and the importance of effective communication and active engagement among all clinical team