Results

Total Results: over 10,000 records

Showing results for "identified".

301. Delayed Diagnosis of Kidney Transplant Complications | PSNet
     psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
     January 29, 2020 - Even some potential causes of allograft dysfunction, such as hydronephrosis, stones, and cysts, can be identified … The subsequent MRA identified kinking of the EIA that was likely a result of a technical problem during … This ultrasound identified a hematoma that was likely related to the radiology procedure as well as decreased … safety, as earlier transplant kidney Doppler ultrasound (i.e., immediately post-transplant) may have identified … post-transplant period, many common vascular and obstructive etiologies of graft dysfunction can be identified

302. Nosy Business | PSNet
     psnet.ahrq.gov/web-mm/nosy-business
     March 01, 2007 - Otolaryngology was consulted and, after removing the tampons, they identified the posterior nasopharynx … When no source can be identified anteriorly, nasal endoscopy should be considered. … Once the source of the bleeding has been identified, cauterization, either chemical with silver nitrate … In certain patients, the source cannot be identified or the bleeding is diffuse, which is more often … First, the bleeding source must be accurately identified and treated.

303. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49650/psn-pdf
     March 01, 2012 - surgery site was marked after the patient confirmed the biopsy site with use of a mirror, two physicians identified … The patient in this case self-identified the wrong surgical site. … In contrast, all biopsy sites were correctly identified when using prebiopsy photographs of skin lesions … surgeries performed; surgery was occasionally deferred because the correct biopsy site could not be identified … If the biopsy site still could not be identified, then frozen biopsy specimens were sent for formalin

304. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836839/psn-pdf
     March 31, 2022 - Perspective authors identified several psychological safety articles across different healthcare settings … Eight facilitators and examples of each facilitator were identified: Leader inclusiveness: introducing … Interestingly, a barrier identified in the systematic analysis study that the authors described as “less … Although facilitators and barriers to psychological safety have been identified, there is still incomplete … Three key themes were identified: (1) impact on bandwidth, (2) context, and (3) motivation to speak

305. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33729/psn-pdf
     May 01, 2012 - to patient safety measurement is worth pursuing, as dramatically different adverse event rates are identified … However, administrative data sets, which are the source of adverse event rates identified by AHRQ's … Practice Study used retrospective chart review to uncover adverse events.(22) Another influential study identified … while the AHRQ Patient Safety Indicators (derived from an algorithm applied to administrative data) identified … 35 adverse events (9%), and occurrence reports identified only 4 https://psnet.ahrq.gov//#ref12 https

306. Annual Perspective: Psychological Safety of Healthcare Staff | PSNet
     psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
     November 16, 2022 - Perspective authors identified several psychological safety articles across different healthcare settings … Eight facilitators and examples of each facilitator were identified: Leader inclusiveness: introducing … Interestingly, a barrier identified in the systematic analysis study that the authors described as “less … Although facilitators and barriers to psychological safety have been identified, there is still incomplete … Three key themes were identified: (1) impact on bandwidth, (2) context, and (3) motivation to speak up

307. Turn the Other Cheek | PSNet
     psnet.ahrq.gov/web-mm/turn-other-cheek
     October 26, 2010 - surgery site was marked after the patient confirmed the biopsy site with use of a mirror, two physicians identified … The patient in this case self-identified the wrong surgical site. … In contrast, all biopsy sites were correctly identified when using prebiopsy photographs of skin lesions … surgeries performed; surgery was occasionally deferred because the correct biopsy site could not be identified … If the biopsy site still could not be identified, then frozen biopsy specimens were sent for formalin

308. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33711/psn-pdf
     May 01, 2011 - medical error has been termed the second victim phenomenon, initially by Wu.(7) Once the phenomenon was identified … "(18) We completed 31 qualitative interviews with individuals identified as potentially suffering from … During iterative analyses, we identified six stages that described the second victim recovery process … individuals to contribute to organizational learning from the event as well as participate in any identified … institution has opted to invite the second victim to participate in the case review to help address identified

309. Do not put medication safety "on hold" with boarded patients. | PSNet
     psnet.ahrq.gov/issue/do-not-put-medication-safety-hold-boarded-patients
     September 24, 2010 - September 29, 2010 Identified safety risks with splitting and crushing oral medications … July 28, 2010 Identified safety risks with splitting and crushing oral medications.

310. The Sociology of Healthcare Safety and Quality. | PSNet
     psnet.ahrq.gov/issue/sociology-healthcare-safety-and-quality
     March 02, 2016 - July 22, 2019 Systematically Identified Failure Is the Route to a Successful Health System … August 15, 2016 Systematically Identified Failure Is the Route to a Successful Health

311. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions | PSNet
     psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
     November 13, 2024 - medical error has been termed the second victim phenomenon, initially by Wu.( 7 ) Once the phenomenon was identified … "( 18 ) We completed 31 qualitative interviews with individuals identified as potentially suffering … During iterative analyses, we identified six stages that described the second victim recovery process … for individuals to contribute to organizational learning from the event as well as participate in any identified … institution has opted to invite the second victim to participate in the case review to help address identified

312. Which End Is Which? | PSNet
     psnet.ahrq.gov/web-mm/which-end-which
     February 09, 2011 - During the surgery, pneumoperitoneum was established and the “floppy descending” colon was identified … The first is that sigmoid colon is appropriately identified, but the distal limb mistakenly brought out … With these initial steps complete, the appropriate segment of colon is mobilized and identified. … inserted through the rectum) allows further confirmation that the correct end of the colon has been identified … June 24, 2010 A comparison of hospital adverse events identified by three widely used

313. Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for children's hospitals. | PSNet
     psnet.ahrq.gov/issue/relevance-agency-healthcare-research-and-quality-patient-safety-indicators-childrens
     July 14, 2010 - Resources From the Same Author(s) Targeted chart review of pediatric patient safety events identified … March 4, 2011 Targeted chart review of pediatric patient safety events identified by

314. Routinely recorded patient safety events in primary care: a literature review. | PSNet
     psnet.ahrq.gov/issue/routinely-recorded-patient-safety-events-primary-care-literature-review
     April 18, 2012 - December 14, 2016 Clinician-identified problems and solutions for delayed diagnosis in … Laboratory test ordering and results management systems: a qualitative study of safety risks identified

315. Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification. | PSNet
     psnet.ahrq.gov/issue/combining-ratings-multiple-physician-reviewers-helped-overcome-uncertainty-associated-adverse
     December 22, 2010 - June 3, 2010 Quality gaps identified through mortality review. … June 28, 2017 Quality gaps identified through mortality review.

316. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33596/psn-pdf
     June 01, 2025 - Weick and others articulated the notion of high reliability organizations (HROs) and identified resilience … The authors identified six types of interventions that can improve FTR rates within healthcare organizations … detecting-patient-deterioration-using-artificial-intelligence-rapid-response-system https://psnet.ahrq.gov//#2 https://psnet.ahrq.gov//#3 https://psnet.ahrq.gov//#4 identified … Hospital and Patient Characteristics Affecting Failure-to-Rescue A 2015 systematic review identified … more likely to die after emergency surgery than patients with private insurance.5 Other studies have identified

317. “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) | PSNet
     psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
     February 26, 2025 - to provide Universal Education about IPV to patients, increase the number of patients screened and identified … Close relationships with community resources are critical to support patients identified for behavioral … of the patient between primary care and community services if any necessary follow-on services were identified … resulting in positive identification of patients who have experienced IPV, the total number of patients identified … Close relationships with community resources are critical to support patients identified for behavioral

318. Submit Case | PSNet
     psnet.ahrq.gov/submit-case-landing
     March 25, 2025 - What You Need to Know Health care professionals may submit de-identified cases that highlight … Write your case This form should only be used to submit de-identified, factual

319. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836876/psn-pdf
     May 16, 2022 - have evolved with time rather than by design.1 Safety events in the prehospital setting are sometimes identified … A recent systematic review identified a median rate of 5.9 incidents per 100 records/transports/patients … /psnet.ahrq.gov//#_edn3 proactive strategies to track, trend, and improve performance in areas of identified

320. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41441/psn-pdf
     July 08, 2021 - https://psnet.ahrq.gov/issue/national-diabetes-inpatient-audit-2017 This annual report identified a