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3001. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon | PSNet
      psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
      January 29, 2021 - A quantitative neuromuscular block monitor was not used but reliance was placed on clinical signs. … [ 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 … Clinical pharmacokinetics of rocuronium bromide. … WebM&M Cases Hurried Team Huddle and Poor Communication: Unsafe Practice

3002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49562/psn-pdf
      May 01, 2008 - references surgery or procedure regardless of where it is being performed.(2) Despite the spirit of these guidelines … reason, New York State now requires that the time out take place immediately prior to the incision, a practice … behavior and apologized to the nurse, but was also told that the nursing staff would be establishing new guidelines … critical points prior to incision, such as just prior to placement of a spinal anesthetic, and this is a practice

3003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49606/psn-pdf
      August 01, 2010 - 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 … be 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 https://psnet.ahrq.gov//#figure https://psnet.ahrq.gov

3004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33756/psn-pdf
      October 01, 2013 - When we looked at patients grouped by clinical condition being assessed—such as PE or stroke—the doses … After we looked into it more closely, it turns out that there were very few guidelines about what doses … It turns out those doses have very little resemblance to the doses used in clinical practice. … It's hard to change practice without having the evidence basis for doing that. … But a private practice radiologist at the end—during a very exciting question and answer and comment

3005. Consequences of Medical Overuse | PSNet
      psnet.ahrq.gov/web-mm/consequences-medical-overuse
      May 05, 2021 - diagnostic tests in everyday medical decision making is seemingly simple, but riddled with error in actual practice … Myocardial infarction is a clinical diagnosis—according to the Universal Definition, "the term acute … Overuse is common and physicians should be on the lookout for it in their practice. … Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria … Interpretation by physicians of clinical laboratory results. N Engl J Med. 1978;299:999-1001.

3006. Delayed Diagnosis of Mesenteric Ischemia | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
      March 31, 2021 - patients and colleagues is a necessary and valuable skill, but sometimes one that is hard to maintain in practice … medicine is thought to be approximately 15%, 16  although this varies significantly by specialty and practice … Acute mesenteric ischemia: a clinical review. … Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. … Clinical reasoning in medicine. Clinical Reasoning in the Health Professions . 1995:49-59.

3007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33665/psn-pdf
      March 01, 2008 - inpatient medical procedures; (ii) better determine when a trainee is competent by assessing both clinical … Direct faculty supervision helps offset the costs of the program, as attendings now generate clinical … intensive learning experience provides the resident multiple, condensed opportunities for deliberate practice … The assessment of clinical skills/competence/performance. Acad Med. 1990;65(suppl 9):S63-S67. … (3)   Table 2: Beth Israel Deaconess Internal Medicine Residency 2007–2008 Procedural Competency Guidelines

3008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50696/psn-pdf
      November 27, 2019 - respiratory compromise due to laryngeal edema and impingement of the airway.10  In this case, the clinical … setting is a reminder of the need for careful, frequent monitoring of all patients’ vital signs and clinical … Clinical decision support features in the EHR can also help to alert medical staff to high-risk patients … Practice guidelines for central venous access: a report by the American Society of Anesthesiologists … Clinical therapeutics. 1997 May 1;19(3):405-19. [go to PubMed] 6.

3009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49637/psn-pdf
      October 01, 2011 - Such timely and effective communication of urgent findings is the recommended practice.( 1,2) Errors … The crucial issue—and point of discrepancy relevant to the clinical management decision—was what the … Radiology and medical malpractice claims: a report on the practice standards claims survey of the Physician … ACR Practice Guideline for Communication of Diagnostic Imaging Findings. … //www.ncbi.nlm.nih.gov/pubmed/9648756 http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines

3010. In Conversation with…Robert M. Wachter, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
      October 01, 2008 - to push the check box in front of the providers and make it very hard to move to the next stage of clinical … Rather, the successes have come from systematizing practice. … patient safety revolution was to get patient safety on the radar screen and to have it be part of the clinical … Hospitals Health Care Providers Health Care Executives and Administrators Gynecology Practice … Guidelines View More

3011. Missed Pneumonia | PSNet
      psnet.ahrq.gov/web-mm/missed-pneumonia
      June 01, 2005 - CAP), resulting in significant morbidity, mortality, and a total cost of more than $10 billion.( 1 ) Guidelines … A thorough history and physical exam must be combined with sound clinical judgment to differentiate these … For example, several well-validated clinical prediction rules have been combined with measurement of … This particular patient's Wells clinical prediction tool for PE results in a score of 1.5 (points are … Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management

3012. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - Monitoring Fetal Health January 1, 2015 Analysis of clinical … December 4, 2016 Clinical decision support alert malfunctions: analysis and empirically … May 20, 2019 Clinical reasoning assessment methods: a scoping review and practical guidance … June 26, 2019 Evaluation of clinical practice guidelines on fall prevention and management

3013. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-295
      June 30, 2021 - Psychological safety has been widely studied in a variety of settings, clinical areas, and patient outcomes … Study Impact of COVID-19 on inpatient clinical emergencies: a single-center experience … The authors outline the hospital response, which included revising RRT guidelines to reduce in-room personnel … Study Reducing failures in daily medical practice: healthcare failure mode and effect … In this commentary, the authors of SEIPS 2.0 and SEIPS 3.0 present a practice-oriented SEIPS model (SEIPS

3014. What Do We Know About Emergency Department Safety? | PSNet
      psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
      June 01, 2010 - (iv) ED systems for teamwork and handoffs as well as guidelines for procedures and checklists should … The effect of clinical experience on the error rate of emergency physicians. … Yet the uptake of clinical decision rules is abysmally low. … July 12, 2017 Improving measurement in clinical handover. … A review of evidence, practice and consumer perspectives.

3015. Slow Down: Right Drug, Wrong Formulation | PSNet
      psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
      October 13, 2018 - As part of the clinical review process, the case was discussed in a morbidity and mortality conference … Schiff, MD Computerized provider order entry (CPOE) systems that incorporate clinical decision support … differentiations of extended-release (SR, ER, SA, XL, XR, CD) compared to immediate-release (IR) products; Clinical … Further standardization and guidelines for computerized provider order entry displays including drug … Amato, PharmD, MPH Department of Pharmacy Practice, MCPHS University, Boston, MA Sponsored Staff Brigham

3016. Saved by ECMO | PSNet
      psnet.ahrq.gov/web-mm/saved-ecmo
      May 05, 2017 - The clinical team suspected inadvertent dural puncture with the epidural catheter, leading to total spinal … June 5, 2024 Improving adherence to long-term opioid therapy guidelines to reduce opioid … December 31, 2014 A clinical pharmacist-led transitions of care program for veterans … July 24, 2024 Assessing the clinical, economic, and health resource utilization impacts … WebM&M Cases Hurried Team Huddle and Poor Communication: Unsafe Practice

3017. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - pathways and protocols, oversight committees to achieve consistency and coordination of care, and clinical … This list should be accessible to faculty, residents, and advanced practice practitioners (APPs), in … Peer review in clinical radiology practice. AJR Am J Roentgenol. 2012;199(2):W158-W162. … Perioperative guidelines on antiplatelet and anticoagulant agents: 2022 update. … Opportunities to improve clinical summaries for patients at hospital discharge.

3018. 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

3019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60721/psn-pdf
      July 21, 2020 - Staff must understand the value of change and innovation and be willing to modify practice to support … The academic societies, including the American Telemedicine Association, have some guidelines for some … Cohen serves as the Lead Clinical Informatics Liaison between the clinical operations and the informatics … Cohen, MD, PhD Lead Clinical Informatics Liaison  Vice-Chair (Innovation, Information, & Technology … [3] Survey: Physician Practice Patterns Changing As A Result of COVID-19. Nerrit Hawkins.

3020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33585/psn-pdf
      March 15, 2025 - and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice … systems-approach https://psnet.ahrq.gov/issue/international-review-patient-safety-measures-radiotherapy-practice … These guidelines call for ordering physicians, radiologists, and technologists to establish a system … guidance to doctors when they enter orders in the system) increases adherence to radiology test ordering guidelines