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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - heightened risk of not only experiencing a fall, but also the associated cascading events such as a bone fracture … you stand up because we’re over treating your blood pressure, you may fall and you could sustain a fracture … hospitalized for something, and is already quite debilitated, falls in the hospital and experiences a hip fracture
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - you stand up because we’re over treating your blood pressure, you may fall and you could sustain a fracture … hospitalized for something, and is already quite debilitated, falls in the hospital and experiences a hip fracture … heightened risk of not only experiencing a fall, but also the associated cascading events such as a bone fracture
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - If soon after the patient was admitted with the leg fracture it was also known he had LBD, the clinical … Concurrent illness (e.g., infections, iatrogenic complications, severe acute illness, anemia, dehydration, fracture
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psnet.ahrq.gov/issue/fire-safety-operating-room
July 18, 2024 - Review
Fire safety in the operating room.
Citation Text:
Fire safety in the operating room. Ehrenwerth J. UptoDate. November 18, 2024.
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psnet.ahrq.gov/issue/technology-education-and-safety-2
December 02, 2020 - Special or Theme Issue
Technology, Education and Safety
Citation Text:
Technology, Education and Safety Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.
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psnet.ahrq.gov/issue/measurement-and-monitoring-safety-canada-cpsi-safety-improvement-project
August 24, 2022 - Multi-use Website
Measurement and Monitoring of Safety Framework
Citation Text:
Measurement and Monitoring of Safety Framework Healthcare Excellence Canada.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - Difficult Encounters
An 89-year-old man was admitted to the orthopedic service after sustaining a hip fracture
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - She was found to have a left hip fracture as a result of the fall and underwent an uncomplicated surgical … sacrum (stage IV full thickness ulcer), which had developed at the long-term care facility after her hip fracture
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psnet.ahrq.gov/issue/disclosure-errors-surgical-procedures
April 13, 2022 - Review
Disclosure of errors in surgical procedures.
Citation Text:
Disclosure of errors in surgical procedures. Ryan M, Mekel M, Sinha MS. UptoDate. November 20, 2023.
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psnet.ahrq.gov/issue/noahs-story-please-listen
June 27, 2018 - Newspaper/Magazine Article
Noah's story: please listen.
Citation Text:
Noah's story: please listen. Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - American man with metastatic squamous
cell carcinoma was admitted to the hospital with a T10 burst
fracture … schizophrenia, developmental delay (not
conserved), and COPD
• Received neurosurgical treatment for the fracture
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - Central line removal can have serious and even fatal complications (air embolism, catheter fracture and … This case illustrates a classic story of gaps or fracture points, in which critical patient information
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - orthopedic surgeon briefly described a 92-year-old woman with a history of dementia who had a left hip fracture … (3)
Early the next day, the patient was taken to the operating room for surgical repair of her hip fracture
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psnet.ahrq.gov/issue/patient-safety-performance-reversing-recent-declines-through-shared-profession-wide-system
December 01, 2021 - Commentary
Patient safety performance: reversing recent declines through shared profession-wide system-level solutions.
Citation Text:
doi:full/10.1056/CAT.22.0318.
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DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/error-traps-acute-pain-management-children
August 24, 2022 - Commentary
Error traps in acute pain management in children.
Citation Text:
Vecchione TM, Agarwal R, Monitto CL. Error traps in acute pain management in children. Paediatr Anaesth. 2022;32(9):982-992. doi:10.1111/pan.14514.
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psnet.ahrq.gov/issue/patient-centered-care-improvement-guide
June 10, 2020 - Book/Report
Patient-Centered Care Improvement Guide.
Citation Text:
Patient-Centered Care Improvement Guide. Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.
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psnet.ahrq.gov/issue/through-and-beyond-anaesthesia-awareness
September 20, 2023 - Commentary
Through and beyond anaesthesia awareness.
Citation Text:
Aaen A-M, Møller K. Through and beyond anaesthesia awareness. BMJ. 2010;341:c3669. doi:10.1136/bmj.c3669.
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psnet.ahrq.gov/issue/human-reliability-analysis-critique-and-review-managers
November 21, 2021 - Review
Human reliability analysis: a critique and review for managers.
Citation Text:
French S, Bedford T, Pollard SJT, et al. Human reliability analysis: A critique and review for managers. Saf Sci. 2011;49(6). doi:10.1016/j.ssci.2011.02.008.
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psnet.ahrq.gov/issue/hospital-discharge-and-readmission
March 27, 2005 - Review
Hospital discharge and readmission.
Citation Text:
Hospital discharge and readmission. Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.
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