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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/issue/good-intention-uncertain-outcomeour-take-physician-dispensing-offices-and-clinics
February 13, 2019 - Consider this...
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psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards
February 03, 2021 - December 29, 2014
Moving beyond misuse and diversion: the urgent need to consider the
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psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes
March 15, 2022 - August 28, 2019
Safety enhancements every hospital must consider in wake of another tragic
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psnet.ahrq.gov/issue/opioid-stewardship
February 06, 2019 - January 11, 2017
Moving beyond misuse and diversion: the urgent need to consider the
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psnet.ahrq.gov/print/pdf/node/866843
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Falls Prevention Awareness Week 2024
Curated Library
Primers
Falls
September, 7 2019
Falls are a common source of patient harm in hospitals, and are considered a never event when they
result in serious injury. Fall prevention requires a coo…
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psnet.ahrq.gov/node/851869/psn-pdf
July 31, 2023 - Taking it one step further, organizations can consider
creating systems to report and analyze successes … Organizations should consider all protections afforded by both state and federal statutes
that promote
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Finally, the radiologist did not consider that the obstructing body might be the Foley catheter and not … Here, it is useful to consider strategies to mitigate secondary harms. … workaround is appropriate (e.g., correct size of Foley catheter, inserted using aseptic technique, etc.), consider
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - and (iii) specific de-biasing would apply to
individual diagnostic areas, such as an admonition to consider … be an ideal place to conduct a formal, conscious review of the diagnoses
being considered, and to consider … Consider the opposite, rethink your key assumptions, and think about
diagnoses that you can't afford
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psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious-adverse-drug-events
June 10, 2018 - Consider this...
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psnet.ahrq.gov/issue/proper-positioning-pharmacy-label-hospira-pca-vials-will-avoid-interference-scanning
May 05, 2018 - Consider this...
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psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
June 10, 2018 - Consider this...
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psnet.ahrq.gov/issue/fatal-drug-mix-exposes-hospital-flaws
March 02, 2016 - June 16, 2019
Safety enhancements every hospital must consider in wake of another tragic
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psnet.ahrq.gov/issue/fda-advise-err-prevent-dangerous-drug-device-interaction-causing-falsely-elevated-glucose
May 02, 2018 - Consider this...
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psnet.ahrq.gov/issue/quality-safety-and-noninterpretive-skills
November 11, 2015 - November 5, 2014
To be sued less, doctors should consider talking to patients more.
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - circumstances of previous fall
Medication adverse effects
Review medications with pharmacist and
physician
Consider … adverse effects of medications used
to treat comorbidities
Consider toileting schedule
Need for assisted … assist to
bathroom, assist to commode, or provide
bedpan
Ambulatory aid at bedside if appropriate
Consider … PT consult
Gait instability
Assist with out of bed: one or two person(s)
Consider PT consult
Lower … limb weakness
Assist with out of bed: one or two person(s)
Consider PT consult
Agitation/Confusion
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - Consider surgical consultation in patients with severe abdominal pain and in patients with peritoneal … ensure that imaging results comport with the history, physical examination, and any abnormal labs, and consider … this case, the clinician should reassess all relevant data, reconsider the differential diagnoses, and consider … Consider surgical consultation in patients with high-risk abdominal pain when imaging is non-diagnostic
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psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
September 27, 2023 - July 28, 2021
Moving beyond misuse and diversion: the urgent need to consider the role
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psnet.ahrq.gov/issue/caregivers-perception-drug-administration-safety-pediatric-oncology-patients
August 14, 2024 - October 14, 2020
It’s time to consider national culture when designing team training
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psnet.ahrq.gov/issue/piece-my-mind-patient-you-least-want-see
August 14, 2024 - April 22, 2015
Moving beyond misuse and diversion: the urgent need to consider the role