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Showing results for "harms".

7881. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47460/psn-pdf
      October 10, 2018 - A surgeon so bad it was criminal. October 10, 2018 Beil L. ProPublica. October 2, 2018. https://psnet.ahrq.gov/issue/surgeon-so-bad-it-was-criminal This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted…

7882. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856641/psn-pdf
      January 01, 2009 - WebAIRS Anesthesia Incident Reporting System. January 1, 2009 Australian and New Zealand Tripartite Anaesthetic Data Committee. https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website serves …

7883. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47696/psn-pdf
      February 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co…

7884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860734/psn-pdf
      January 17, 2024 - These patients had to lobby for correct diabetes diagnoses. Was their race a reason? January 17, 2024 Sable-Smith B. KFF Health News. January 9, 2024. https://psnet.ahrq.gov/issue/these-patients-had-lobby-correct-diabetes-diagnoses-was-their-race-reason Implicit biases can contribute to extended misdiagnoses.…

7885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73454/psn-pdf
      June 30, 2021 - Poor physician-patient communication and medical error. June 30, 2021 Lazris A, Roth AR, Haskell H, et al. Am Fam Physician. 2021;103(12):757-759.   https://psnet.ahrq.gov/issue/poor-physician-patient-communication-and-medical-error Communication failures are primary threat to safe care. This comment…

7886. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37023/psn-pdf
      September 24, 2010 - Applying the Toyota Production System: using a patient safety alert system to reduce error. September 24, 2010 Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386. https://psnet.ahrq.gov/issue/applying-toyot…

7887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60905/psn-pdf
      September 09, 2020 - Doctors turned my sister away; less than two years later she died of cervical cancer. September 9, 2020 Harvey-Jenner C. Cosmopolitan. August 27, 2020.  https://psnet.ahrq.gov/issue/doctors-turned-my-sister-away-less-two-years-later-she-died-cervical-cancer Implicit biases are known to impact effective diagno…

7888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846459/psn-pdf
      March 22, 2023 - Few hospitals are willing to bear the cost of providing psychiatric care for kids. March 22, 2023 Schorsch K, Karp S. WBEZ Chicago. March 9, 2023. https://psnet.ahrq.gov/issue/few-hospitals-are-willing-bear-cost-providing-psychiatric-care-kids Pediatric mental health is a patient safety concern. This news story ou…

7889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50646/psn-pdf
      November 06, 2019 - My patient almost died from a mistake I made. I apologized and it changed my life. November 6, 2019 McLean K. Huffington Post. October 16, 2019. https://psnet.ahrq.gov/issue/my-patient-almost-died-mistake-i-made-i-apologized-and-it-changed-my-life Medical mistakes cause stress for both patients and their clinician…

7890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44278/psn-pdf
      July 01, 2015 - When doctors don't talk to doctors. July 1, 2015 Bond A. https://psnet.ahrq.gov/issue/when-doctors-dont-talk-doctors Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding ho…

7891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60284/psn-pdf
      April 29, 2020 - Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them. April 29, 2020 Washington, DC: United States Government Accountability Office; March 2020. Publication GAO-20- 248. https://psnet.ahrq.gov/issue/trends-pregnancy-related-deaths-and-federal-efforts-reduce-them Maternal harm is a sentinel e…

7892. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73327/psn-pdf
      January 25, 2022 - ISMP Medication Safety Self Assessment® for Perioperative Settings. January 25, 2022 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings The perioperative setting is a high-risk area for medication errors, should they occur. This asses…

7893. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862621/psn-pdf
      February 14, 2024 - Toward the eradication of medical diagnostic errors. February 14, 2024 Topol EJ. Toward the eradication of medical diagnostic errors. Science. 2024;383(6681):eadn9602. doi:10.1126/science.adn9602. https://psnet.ahrq.gov/issue/toward-eradication-medical-diagnostic-errors Artificial intelligence (AI) is being touted…

7894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60260/psn-pdf
      April 22, 2020 - Joint Statement on Multiple Patients Per Ventilator. April 22, 2020 The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for Respiratory Care, American Society of Anesthesiologists, American Association of Critical?Care Nurses, and American College of Chest Physicians. M…

7895. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44142/psn-pdf
      May 03, 2016 - Symposium: Patient Safety: Collaboration, Communication, and Physician Leadership. May 3, 2016 Herndon JH, ed. Clin Orthop Relat Res. 2015;473:1544-1551;1566-1597;1600-1608;1612-1619. https://psnet.ahrq.gov/issue/symposium-patient-safety-collaboration-communication-and-physician- leadership Articles in this speci…

7896. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39532/psn-pdf
      June 27, 2011 - Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. June 27, 2011 Simons PAM, Houben RMA, Backes HH, et al. Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Int J Qual Health Care. 2010;22(3):187-193. doi:10.1093/intqhc/mzq020. h…

7897. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43509/psn-pdf
      September 10, 2014 - Patient Safety in Private Hospitals: the Known and the Unknown Risk. September 10, 2014 Leys C, Toft B. London, UK: Centre for Health and the Public Interest; August 2014. https://psnet.ahrq.gov/issue/patient-safety-private-hospitals-known-and-unknown-risk This report discusses issues with staffing, equipment, and…

7898. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43029/psn-pdf
      March 12, 2014 - ISMP Canada identifies themes associated with fatal medication events in the home. March 12, 2014 ISMP Medication Safety Alert! Acute Care Edition. February 27, 2014;19:1-4. https://psnet.ahrq.gov/issue/ismp-canada-identifies-themes-associated-fatal-medication-events-home Summarizing results from a Canadian study …

7899. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45899/psn-pdf
      March 15, 2017 - Patient Safety: Investigating and Reporting Serious Clinical Incidents. March 15, 2017 Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169. https://psnet.ahrq.gov/issue/patient-safety-investigating-and-reporting-serious-clinical-incidents Research is increasingly focusing on patient safety in primary ca…

7900. 50. What's New in 2008? 2000 Recommendations Changed for 2008 (Continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide50.html
      October 01, 2014 - 50. What's New in 2008? 2000 Recommendations Changed for 2008 (Continued) Treating Tobacco Use and Dependence: 2008 Update Text version of slide presentation. Children and Adolescents (Continued): 2000 Guideline: Recommendation #2: Clinicians in a pediatric setting should offer Smoking cessation advice…