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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was brought to the Pediatric Emergency … In this case, the emergency medicine clinicians were clearly concerned about the
possibility of abuse … imaging
only in asymptomatic children undergoing child abuse evaluation, such as the sibling of an index … Pediatrics
UC Davis Health
jyuk@ucdavis.edu
Julia Magana, MD
Associate Professor
Department of Emergency … Medicine, Pediatric Emergency Medicine
UC Davis Health
https://psnet.ahrq.gov//#4
https://psnet.ahrq.gov
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - heavily on other methods of communication such as verbal report, "cheat sheets," sign off records (index … Voluntarily reported emergency department errors. J Patient Saf. 2005;1:126-132. 12. … Strategies used by nurses to recover medical errors in an academic emergency department setting. … December 12, 2012
Voluntarily reported emergency department errors. … January 12, 2011
Emergency department medication lists are not accurate.
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Given the rarity of spontaneous fungal empyema, the index of suspicion for an esophageal source should … Take Home Points
Esophageal perforation is a rare and serious but surgically treatable emergency
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - chance of detecting such failure, and its impact are combined numerically to produce a criticality index … that independent groups can reach widely differing opinions about the failure modes and criticality index … (In the emergency department, naloxone use would more likely represent treatment of a self-inflicted
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - I'm also an EMT [emergency medical technician] and have been one for about a decade now. … Every year we release an EMS ESO index, and two of the measures that we're looking at are centered around … In last year's index, we saw, across all of those organizations, that only about 80% of records with … Adverse events in prehospital emergency care: a trigger tool study. … Medicine
Emergency Nursing
Active Errors
Latent Errors
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psnet.ahrq.gov/web-mm/recurrent-appendicitis
January 15, 2020 - The Case An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain … One approach to decreasing technical errors for emergency general surgery procedures in the era of increased … Clinicians must have a high index of suspicion for appendicitis in elderly patients with abdominal pain … Weighty Issue
August 21, 2013
WebM&M Cases
Emergency
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - Compared to other medical professions, emergency medical services (EMS) is a relative newcomer in the … I'm also an EMT [emergency medical technician] and have been one for about a decade now. … Every year we release an EMS ESO index, and two of the measures that we're looking at are centered around … In last year's index, we saw, across all of those organizations, that only about 80% of records with … Adverse events in prehospital emergency care: a trigger tool study.
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psnet.ahrq.gov/perspective/emergence-application-based-healthcare
August 05, 2022 - of the smartphone is placed on the left side of the chest while the patient then places their right index
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - following cardiac surgery, resulting in postoperative hypotension despite a normal or increased cardiac index … Assessing volume status and fluid responsiveness in the emergency department. … Clinical and experimental emergency medicine. 2014 Dec;1(2):67. … Emergency Medicine Australasia. 2020 Apr;32(2):220-7. Daroca-Pérez R, Carrascosa MF. … New release: Medication Error Council promotes categorization index. 1996 Sept 4. ECRI Institute.
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - Two weeks after surgery, the patient went to an emergency department (ED) seeking treatment for worsening … risk factors were male sex, younger age, tobacco or alcohol use, obesity or morbid obesity (body mass index … disease, chronic liver disease, chronic lung disease, chronic kidney disease, and depression. 23,24 The severity … should leave instructions as to answers that would trigger an urgent office visit and, in some cases, emergency … Advise the patient on what constitutes an emergency and provide instructions on seeking immediate care
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - patients with acute traumatic injuries The Case A 38-year-old non-English speaking man with a body mass index … Attempts at endotracheal intubation were unsuccessful, so an emergency cricothyroidotomy was performed … The patient underwent emergency laminectomy and decompression but had persistent virtually complete paralysis … This is an inexcusably long period for a finding that could represent any of several neurologic emergencies … Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - the patient begin post-dates surveillance with twice weekly NST/AFI (Non Stress Test/Amniotic Fluid Index … Palliative Care
November 30, 2021
Optimizing situation awareness to reduce emergency
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - and all compound IV solutions with dextrose concentrations greater than 10% should have a refractive index … directors of pharmacy or their designees, out of 300 respondents, 87% reported that the shortages impacted emergency … April 8, 2019
Use of an emergency manual during an intraoperative cardiac arrest by an
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - The therapeutic index (ratio between toxic dose and therapeutic dose, a measure of the relative safety … Less commonly, patients experience an increase in the frequency or severity of seizures during phenytoin … of antiseizure drugs are challenging due to the need to individualize therapy, the low therapeutic index … continue to be increased as long as the patient derives incremental benefit in seizure frequency (or severity
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - Control and Prevention (CDC) defines overweight and obesity in adults 19 years and older as body mass index … High body mass index for age among US children and adolescents, 2003-2006. … Emergency department management of adolescents with urinary complaints: missed opportunities. … Pregnant adolescents in the emergency department: diagnosed and not diagnosed. … a Missed Diagnosis
February 23, 2022
Adverse glycemic events and critical emergencies
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Age, female sex, and lower body mass index (BMI) appear to be risk factors
for oversedation requiring
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - To facilitate efforts to compile and index events across institutions, AHRQ has posted standardized reporting … something that needs a really timely root cause analysis done right now—something that because of its severity … obstetrician is not going to want to fill out the same type of form that a general internist might or an emergency
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - study them, individually and collectively, to ensure that they actually do reduce the frequency and severity … Association of interruptions with and increased risk and severity of medication administration errors … Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking … and see a patient, they automatically say to themselves, "I was just interrupted," and they pull an index … January 31, 2018
Quality and safety implications of emergency department information
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Age, female sex, and lower body mass index (BMI) appear to be risk factors for oversedation requiring
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - Other factors associated with lower warfarin requirements include a body mass index (BMI) less than 20 … September 26, 2018
Optimizing situation awareness to reduce emergency transfers in hospitalized … Opioid-Induced Respiratory Depression
May 27, 2020
Preventing adverse events caused by emergency