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psnet.ahrq.gov/issue/estimating-breast-cancer-overdiagnosis-after-screening-mammography-among-older-women-united
October 19, 2022 - Study
Estimating breast cancer overdiagnosis after screening mammography among older women in the United States.
Citation Text:
Richman IB, Long JB, Soulos PR, et al. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Ann Intern Med…
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psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue
June 18, 2019 - Study
Interpersonal and organizational dynamics are key drivers of failure to rescue.
Citation Text:
Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.201…
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psnet.ahrq.gov/issue/safety-surgical-telehealth-outpatient-and-inpatient-setting
September 13, 2023 - Review
Safety of surgical telehealth in the outpatient and inpatient setting.
Citation Text:
Purnell S, Zheng F. Safety of Surgical Telehealth in the Outpatient and Inpatient Setting. Surg Clin North Am. 2020;101(1):109-119. doi:10.1016/j.suc.2020.09.003.
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psnet.ahrq.gov/issue/investigating-mediating-effect-patient-self-efficacy-relationship-between-patient-safety
September 08, 2021 - Study
Investigating the mediating effect of patient self-efficacy on the relationship between patient safety engagement and patient safety in healthcare professionals.
Citation Text:
Wang X, Zhao Y. Investigating the mediating effect of patient self-efficacy on the relationship between p…
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psnet.ahrq.gov/issue/culture-safety-impact-improvement-infection-prevention-process-and-outcomes
September 23, 2020 - Review
Culture of safety: impact on improvement in infection prevention process and outcomes.
Citation Text:
Braun B, Chitavi SO, Suzuki H, et al. Culture of Safety: Impact on Improvement in Infection Prevention Process and Outcomes. Curr Infect Dis Rep. 2020;22(12):34. doi:10.1007/s1190…
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psnet.ahrq.gov/issue/raising-alarm-cross-sectional-study-exploring-factors-affecting-patients-willingness-escalate
September 12, 2016 - Study
Raising the alarm: a cross-sectional study exploring the factors affecting patients' willingness to escalate care on surgical wards.
Citation Text:
Johnston MJ, Davis R, Arora S, et al. Raising the Alarm: A Cross-Sectional Study Exploring the Factors Affecting Patients' Willingness…
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Since the surgeon did not notice
excessive bleeding, he initially continued with the procedure. … Are you sure she isn't bleeding? We should stop the
procedure and figure out what's wrong." … forcefulness, he recognized her concern, stopped the procedure, and began searching for a source of
bleeding … Third, she stated what she felt was the perceived
problem of unrecognized hemorrhage.
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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - showed some brain atrophy, small, old strokes, and a large left-sided subdural hygroma, but no acute
hemorrhage … These demonstrated the acute subdural hemorrhage for which the patient had been transferred.
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - The cardiologist obtained and reviewed echocardiographic images, which revealed bleeding around the heart … . 7 Very rarely, bleeding complications can present as coronary dissection/perforation or left ventricular … Patient-related factors associated with increased risk of periprocedural bleeding include therapeutic … The prognostic value of Bleeding Academic Research Consortium (BARC)-defined bleeding complications in … Predictors and impact of major hemorrhage on mortality following percutaneous coronary intervention from
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - subcategories of trauma resuscitation: airway management, ventilation and chest
decompression, management of bleeding … prompts might remind staff
working with a patient with abnormally low blood pressure to control external hemorrhage … The program had a particularly
large impact on the use of pressure dressings to control hemorrhage (
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psnet.ahrq.gov/issue/effect-cognitive-aids-adherence-best-practice-treatment-deteriorating-surgical-patients
September 30, 2020 - Study
Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting.
Citation Text:
Koers L, van Haperen M, Meijer CGF, et al. Effect of Cognitive Aids on Adherence to Best Practice in the T…
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psnet.ahrq.gov/issue/adverse-event-and-complication-tracking-anaesthesiology-dependence-self-reporting-despite
March 17, 2021 - Commentary
Adverse event and complication tracking in anaesthesiology: dependence on self-reporting despite implementation of electronic health records.
Citation Text:
Tewfik G, Naftalovich R, Kaushal N, et al. Adverse event and complication tracking in anaesthesiology: dependence on sel…
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psnet.ahrq.gov/issue/autopsy-interrogation-emergency-medicine-dispute-cases-how-often-are-clinical-diagnoses
March 24, 2019 - Study
Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect?
Citation Text:
Liu D, Gan R, Zhang W, et al. Autopsy interrogation of emergency medicine dispute cases: how often are clinical diagnoses incorrect? J Clin Pathol. 2018;71(1):67-71…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - Vaginal packing is commonly used in obstetrics, usually in the management of hemorrhage, but is also … iodoform gauze) that is forcefully and tightly placed in a cavity, orifice, or wound, usually to control bleeding … This is not an endless chain of events, as orific e packing for hemorrhage control rarely lasts longer … any material that is forcefully and tightly placed in a cavity, orifice, or wound, usually to control bleeding … October 11, 2023
Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage
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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - ) of the head showed a left cerebellar hypodensity concerning for ischemic stroke, intraventricular hemorrhages
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - found to have an INR of 4.0 (an abnormally high level that is associated with an increased risk of bleeding … Fortunately, even though he had fallen twice in the previous week, he had no significant bleeding. … Bleeding complications with warfarin use: a prevalent adverse effect resulting in regulatory action. … Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin … reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding
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psnet.ahrq.gov/print/pdf/node/73848
July 01, 2022 - a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from
hemorrhage … a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from
hemorrhage
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - showed some brain atrophy, small, old strokes, and a large left-sided subdural hygroma, but no acute hemorrhage … These demonstrated the acute subdural hemorrhage for which the patient had been transferred.
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psnet.ahrq.gov/continuing-education
February 26, 2025 - However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition … The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with … unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding … The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding