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Total Results: 6,759 records

Showing results for "described".

621. Chest Tube Complications | PSNet
     psnet.ahrq.gov/web-mm/chest-tube-complications
     September 27, 2023 - Chest tube complications have been described most often in the trauma literature, with incidences varying … to help guide nurses in when to remove chest tubes.( 13,14 ) Unfortunately, clamping trials are not described … Funk and colleagues ( 15 ) have described a chest tube care path that outlines an algorithm for safe

622. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49857/psn-pdf
     March 01, 2019 - insulin-related hypoglycemia and errors occur annually, with 30% resulting in hospital admission.(2) One report described … In the case described, several factors contributed to the error at each phase of the medication-use process … orders, as seen in this case, have also been found to be higher during handoff times.(9) One study described

623. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. | PSNet
     psnet.ahrq.gov/issue/ten-challenges-improving-quality-healthcare-lessons-health-foundations-programme-evaluations
     February 19, 2020 - June 16, 2021 How well is quality improvement described in the perioperative care literature

624. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
     February 26, 2025 - , the seminal Institute of Medicine report that drew attention to patient safety, medical error is described … HRO principles have been described as having five characteristics: Preoccupation with failure: Awareness … , an academic medical center and safety net hospital, the University of Mississippi Medical Center, described … Sarah Mossburg: High reliability organizing is often described as a mindset, with five characteristics … Sarah Mossburg: High reliability was first described in industries outside health care, as you mentioned

625. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
     February 26, 2025 - Sarah Mossburg: High reliability organizing is often described as a mindset, with five characteristics … Sarah Mossburg: High reliability was first described in industries outside health care, as you mentioned … , the seminal Institute of Medicine report that drew attention to patient safety, medical error is described … HRO principles have been described as having five characteristics: Preoccupation with failure: Awareness … , an academic medical center and safety net hospital, the University of Mississippi Medical Center, described

626. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head | PSNet
     psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
     March 27, 2024 - subdural hematomas have been reported to occur after initially negative head CTs, as in the patient described … Olivero and colleagues described 37 patients who underwent surgery for chronic subdural hematomas, 7 … In a series described by Amrhein and colleagues, 25 the sensitivity and specificity of a non-enhanced … with concentration and memory were attributed to the prior concussion (a cognitive bias sometimes described

627. Responding to Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/responding-patient-safety-events
     October 18, 2023 - Event reporting , investigation , and data tracking have been described in other primers. … As described in the CANDOR toolkit, components of an apology should include acknowledging the gaps

628. How Do Providers Recover From Errors? | PSNet
     psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
     May 22, 2024 - that such errors are common, but better tracking is needed before these rates can be more accurately described … While some legal experts may highlight the perceived risk of full error disclosure (as described in this … there are relatively few formal support programs available for providers after errors occur.( 6 ) As described

629. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73455/psn-pdf
     June 30, 2021 - She described it as “not a black-out but a feeling of a white-out” occurring roughly once every month … a time when she was feeling particularly stressed, she experienced a more severe episode that she described … This sensation is described by patients in a variety of ways such as a forceful or irregular heartbeat

630. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836839/psn-pdf
     March 31, 2022 - Interestingly, a barrier identified in the systematic analysis study that the authors described as “less … The areas of action are described as having three core pillars for ultimate outcomes of psychologically … Adaptation of existing measures for assessing psychological safety has been described, and one study

631. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49864/psn-pdf
     June 01, 2019 - things to go well in the health care setting and are only possible in an environment that can best be described … In the case described above, a patient care assistant spoke up after witnessing a physician making a … In the vignette described above, we know that the patient care assistant did speak up.

632. Safeguarding Diagnostic Testing at the Point of Care | PSNet
     psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
     September 30, 2011 - The simplest point-of-care tests, such as the urine pregnancy test described in this case, can be performed … require manual result entry into middleware or the patient record, as seen with the urine pregnancy test described … The type of pregnancy testing described in this case is CLIA waived.

633. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49819/psn-pdf
     February 01, 2018 - due to a preventable adverse event in hospital, a series of errors contributed to the tragic outcome described … A more explicitly described contingency plan regarding the exact dose and route of heparin to be initiated … well as improved handoff quality and reductions in handoff-related adverse events such as the event described

634. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49764/psn-pdf
     June 01, 2016 - In the scenario described above, the referring ED physician did not appropriately communicate the specific … Consultation," to highlight the general principles to be followed by a consultant.(2) In the case described

635. 'Speaking Up' for patient safety and staff well-being: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/speaking-patient-safety-and-staff-well-being-qualitative-study
     November 16, 2016 - September 23, 2017 How well is quality improvement described in the perioperative care

636. Communication about harm reduction with patients who have opioid use disorder. | PSNet
     psnet.ahrq.gov/issue/communication-about-harm-reduction-patients-who-have-opioid-use-disorder
     January 02, 2017 - June 16, 2021 How well is quality improvement described in the perioperative care literature

637. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49412/psn-pdf
     September 01, 2003 - study, with 7% having the potential for harming the patient.(4) Wrong dose errors, such as the case described … omission error may be a possible explanation.(4) The investigation following the suspected error described

638. Duplicate Insulin Order | PSNet
     psnet.ahrq.gov/web-mm/duplicate-insulin-order
     May 04, 2012 - insulin-related hypoglycemia and errors occur annually, with 30% resulting in hospital admission.( 2 ) One report described … In the case described, several factors contributed to the error at each phase of the medication-use process … orders, as seen in this case, have also been found to be higher during handoff times.( 9 ) One study described

639. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49552/psn-pdf
     January 01, 2008 - that such errors are common, but better tracking is needed before these rates can be more accurately described … While some legal experts may highlight the perceived risk of full error disclosure (as described in … there are relatively few formal support programs available for providers after errors occur.(6) As described

640. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33663/psn-pdf
     September 15, 2008 - Conclusion The path to a totally safe hospital or health system can be best described as a journey. … This report has described steps from our particular journey at AHS. … psnet.ahrq.gov//#ref7 https://psnet.ahrq.gov//#ref8 https://psnet.ahrq.gov//#figure This report has described