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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - clinicians fail to make the diagnosis of compartment syndrome in a timely manner, the patient ends up … Every team member should be encouraged to speak up and voice any concerns about the patient’s position … WebM&M Cases
Unintentional Ketamine Overdose in the Operating Room – Mixing Up
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - organizational culture (hierarchy
and intimidation, failure to function as a team, and failure to follow … route
to establishing and sustaining a robust simulation program is to enlist both top-down and bottom-up
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - When appropriate, the plan follows up with a contracted facility to determine if corrective action plans … Examples of follow-up may include requesting policies and
procedures, reviewing training content and
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - I was a bit shaken up and because I was not sure of the cause, I took her to see her pediatrician. … exam on his wife when she complained of pain shortly after suffering an apparent miscarriage, coming up
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Studies report medication error rates between 5 to 11 percent of all medication administrations,
with up … have advocated for several additions to the classic five rights, with some organizations
suggesting up … Lack of documentation and failure to follow appropriate procedure
when it comes to wasting medications
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - Although sensitivity of up to 100% has been reported for CT scans of the appendix ( 6 ), in typical practice … On hospital day #13, she was discharged to home with a plan to follow-up for elective appendectomy.
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - 73-year-old man with a long-standing cardiac arrhythmia came to the ambulatory clinic for a routine follow-up … Virtually all pharmacies have access to drug information with online information being more up-to-date … Drug names that look alike are easily confused, and a mix-up between Rythmol and Synthroid is plausible
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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - recent interest has focused on improving communication and teamwork, clinical decision support, and
follow-up
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - telephone application that provided patient
education and self-management support with targeted nurse follow-up
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Her work up revealed profound anemia due to brisk autoimmune hemolysis. … antibiotic prescribing remains common, especially for acute respiratory infections
Clinicians should follow
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psnet.ahrq.gov/web-mm/more-treatment-better-care
August 11, 2021 - The Medical Director reviewed the risks of plasmapheresis with the physician and asked him to follow … The delivery of safe and effective test result communication, management and follow-up
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - 2)
• Medication errors are common in the hospital setting and can cause adverse drug
events.25
– Up … have been beneficial for the CDS system to include AWS-specific
clinical parameters for interval up-titration … abuse treatment programs, other psychiatric care when
needed, social interventions and primary care follow-up
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - interpersonal risk taking.” 2 The term embodies individual confidence in the belief that speaking up … In turn, safety motivation had a positive effect on safety voice, which is the act of speaking up about … confidently (individual level)
Chairing meetings: appointed meeting chairs are motivated to speak up … For the third theme, motivation to speak up, a team member may not be motivated by patient safety to … December 1, 2010
"Managing up" can improve teamwork in the OR.
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - doctors in emergency departments and
found that for both groups, about 80% of their time was taken up … workers are
stressful and sometimes exceed the capacity of "merely extraordinary" human beings to keep up … positioned to solve the problem.(11) The nurse in this situation did not feel that she
could speak up … Intimidation: practitioners speak up about this unresolved problem (part I).
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - [As another example,] if you’re getting dizzy every time you stand up because we’re over treating your … I’m weak, but I haven’t lost so much muscle mass to the point that I can’t get up and walk around. … I recover that function, but maybe it’s led to functional incontinence because I’m not able to get up … Many frail older patients will have a family member fill up pill boxes for them. … What keeps me up at night is any harm that we might cause to the patient.
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - [As another example,] if you’re getting dizzy every time you stand up because we’re over treating your … I’m weak, but I haven’t lost so much muscle mass to the point that I can’t get up and walk around. … I recover that function, but maybe it’s led to functional incontinence because I’m not able to get up … Many frail older patients will have a family member fill up pill boxes for them. … What keeps me up at night is any harm that we might cause to the patient.
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - The patient said “yes” and was discharged to be seen in the office for
follow-up. … the documentation tool used at each shift and each handoff) moves the information about
the packing up … Aggression in clinical settings: nurses' views, a follow study.
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psnet.ahrq.gov/node/866826/psn-pdf
September 25, 2024 - When gas flow is
linked, anesthesia clinicians cannot accidentally dial up a hypoxic gas mixture because … Cold pre-mixed cylinders therefore should be warmed up
in the upright position for 24 hours before use … The clinicians dial up the oxygen concentration they would like to deliver, and the
machine adjusts … situation is easily
recognized because the low oxygen alarm will sound if the system has been set up
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - The flow of fluid through the humeral head is superior—up to five times
higher—to that in the tibial
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - The provider´s referral of this patient to the local ED, and follow-up call to learn the results of the