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3021. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) | PSNet
      psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
      April 01, 2005 - If there was an immediate risk to the patient, then they could intervene immediately with the clinical … because the observers were seeing something that was evolving but simply because they were present when clinical … something—for example, once one of the observers noticed an x-ray hanging backwards—they pointed it out to clinical … whatever new ACGME guidelines are developed?

3022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853081/psn-pdf
      August 30, 2023 - at the highest scope of their practice. … VIC also enables us to use clinical roles that some of the hospitals had stopped using, such as licensed … That’s the same with those of us in executive practice. … Lincoln, the physicians took the command center and would do rounds with patients because Medicare guidelines … Every state has different scope of practice laws for health professionals.

3023. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet
      psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
      September 27, 2023 - “High-risk” abdominal pain is characterized by clinical features including age greater than 65 years, … American College of Radiology (ACR) Appropriateness Criteria (AC) are annually updated “evidence-based guidelines … Based on certain clinical and testing parameters, the use of lactate levels can be considered in the … ACR guidelines are available to guide physician choice of appropriate imaging. … Don’t ignore abnormal clinical findings.

3024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841566/psn-pdf
      December 14, 2022 - Michelle Schreiber: I am the Deputy Director of the Center for Clinical Standards and Quality (CCSQ) … Michelle Schreiber: CCSQ is the clinical and quality center, to a large degree, of CMS. … Last year, we introduced two new electronic clinical quality measures (eCQMs) for glycemic control. … Electronically is important for a number of reasons; one is the robust clinical information from an … guidelines and to clinical decisions and support and to ongoing and iterative quality improvement.

3025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49712/psn-pdf
      June 01, 2014 - Moreover, while many guidelines promote medication review and counseling, physicians receive limited … A pharmacy practice can also be very busy, and patients may not find it easier to ask for guidance there

3026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74242/psn-pdf
      January 07, 2022 - biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice … WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives.

3027. Monitoring Fetal Health | PSNet
      psnet.ahrq.gov/web-mm/monitoring-fetal-health
      September 08, 2010 - monitoring.( 9 ) At present, however, there are no agreed upon standards for comparing computerized and clinical … Andrews Professor & Chairman Associate Dean for Clinical Affairs Department of Obstetrics and Gynecology … workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines … WebM&M Cases Hurried Team Huddle and Poor Communication: Unsafe Practice

3028. Mother's Milk, but Whose Mother? | PSNet
      psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
      November 15, 2023 - A prevalent health care practice is to "name, blame" and hold accountable the person closest to the error … 0.00064 per liter of breast milk ingested and 0.00028 per day of breastfeeding.( 7 ) Developed countries practice … Nonetheless, the recommended practice is to provide immunoglobulin and HBV vaccine after birth to the … Robbins ST, Beker LT, Pediatric Nutrition Practice Group. … Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities.

3029. Doctor, Don't Treat Thyself | PSNet
      psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
      August 21, 2024 - However, even those physicians who do have their own doctor often register with a personal friend or a practice … Elin Olaug Rosvold, MD, PhD Assistant Professor Department of General Practice and Community Medicine … Oslo, Norway: Institute of General Practice and Community Medicine, University of Oslo; 2002.  … Doctors as patients: postal survey examining consultants and general practitioners adherence to guidelines … An analysis of the practice of physicians' treating their own families.

3030. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery | PSNet
      psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
      January 29, 2021 - The exact pressure that requires fasciotomy depends on the clinical circumstances and the evolution over … Christian Bohringer, MBBS Consulting Editor, AHRQ's Patient Safety Network (PSNet)  Professor of Clinical … Guidelines. … Complicated Central Line Insertion Leads to Cardiac Arrest January 26, 2022 Clinical … surgical patient safety system and the World Health Organization's checklists in surgery: a nonrandomized clinical

3031. An Obstructed View | PSNet
      psnet.ahrq.gov/web-mm/obstructed-view
      August 07, 2019 - This case illustrates the difficulty in diagnosing a strangulating bowel obstruction on the basis of clinical … As this case illustrates, a patient can have strangulated bowel with no clinical or radiographic predictors … Here's a practice pearl: "Obstructions destined to resolve nonoperatively generally do so within 72 hours … No clinical signs, symptoms, laboratory values, or radiographic findings reliably identify patients with … Usefulness of known computed tomography and clinical criteria for diagnosing strangulation in small-bowel

3032. Think Like a Surgeon | PSNet
      psnet.ahrq.gov/web-mm/think-surgeon
      December 04, 2024 - and 90% specificity. 8  In this case, where the differential diagnosis was broad due to a nonspecific clinical … greater complication risk, and increased cost. 11-13  Therefore, surgeons should be engaged early in the clinical … missed diagnosis in patients with acute abdominal pain. 18  Miscalibration, or confidence in inaccurate clinical … A population-based analysis of the clinical course of 10,304 patients with acute cholecystitis, discharged … An effective program to reduce malpractice claims and payments in a large orthopaedic practice

3033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866261/psn-pdf
      July 10, 2024 - The exact pressure that requires fasciotomy depends on the clinical circumstances and the evolution … Christian Bohringer, MBBS Consulting Editor, AHRQ's Patient Safety Network (PSNet)  Professor of Clinical … compartment syndrome after prolonged pelvic surgery: launch of United Kingdom and Ireland Multidisciplinary Clinical … Guidelines.

3034. Long-term Care and Patient Safety | PSNet
      psnet.ahrq.gov/primer/long-term-care-and-patient-safety
      February 24, 2022 - infection preventionists AHRQ infection control training Detailed instructions, policies and procedure guidelines … These require SNFs to have measures in place to prevent specific clinical harms (such as falls, pressure … PSNet primers are regularly reviewed and updated to ensure that they reflect current research and practice

3035. Maternal Safety | PSNet
      psnet.ahrq.gov/curated-library/maternal-safety
      January 31, 2024 - importance of coordinated teamwork during obstetric emergencies, this review discusses strategies to augment clinical … Organizational Policy/Guidelines National Partnership for Maternal Safety: consensus … The authors discuss relational rehearsal, system structuring, and practice elaboration as elements of … Agency for Healthcare Research and Quality adapted its Comprehensive Unit-based Safety Program, a best practice

3036. Blind Spot | PSNet
      psnet.ahrq.gov/web-mm/blind-spot
      July 30, 2020 - Though we lack detailed ophthalmologic exams on this patient, her clinical course most closely resembles … Clinical features and pathogenesis of post-hemorrhagic amaurosis. … Clinical features of non-arteritic and arteritic AION. Available at Accessed June 6, 2005. … February 7, 2018 Perception of safety of surgical practice among operating room personnel

3037. Medication Safety in Nursing Homes: What's Wrong and How to Fix It | PSNet
      psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
      August 01, 2012 - Unanticipated safety risks continue to emerge ( 10 ), and recent guidelines advise that these agents … decision support systems that incorporate relevant clinical information. … Even sophisticated computerized clinical decision support systems, when implemented in isolation and … Computerized physician order entry with clinical decision support in long-term care facilities: costs … May 26, 2011 Development and pilot testing of guidelines to monitor high-risk medications

3038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60268/psn-pdf
      April 29, 2020 - psnet.ahrq.gov//#10 computed tomography (CT) or operating room.12,13 Staff training and education Guidelines … it appears that only the perfusionist had the knowledge necessary to diagnose the issue, leading to clinical … Cardiothoracic Intensive Care Unit: A Review of Handoffs in Perioperative Cardiothoracic and Vascular Practice … of an improvement of experience and training in extracorporeal membrane oxygenation management on clinical … Simulation-Based Assessment of ECMO Clinical Specialists. Simul Healthc. 2016;11(3):194–199.

3039. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73153/psn-pdf
      April 28, 2021 - been placed, usually by a physician, retention typically results from a concatenation of errors in practice … A “best practice” process has been designed whereby the nurse circulator places a specifically designed … It is difficult to know what barriers interfere with this practice and there is little literature on … The hospital’s culture should support nurses to raise scope of practice questions when they are asked … Aggression in clinical settings: nurses' views, a follow study.

3040. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet
      psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
      May 01, 2018 - Furthermore, it is common practice to administer fluids to hospitalized patients with evidence for improved … evaluation, the treating clinicians changed course, administering IV loop diuretics in accord with usual practice … Proper use of checklists , treatment algorithms, or clinical decision support tools might prevent … Were all ICU beds full at the time of admission, with administrative or clinical barriers to transferring … The role of the clinical examination in patients with heart failure.