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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - The indications for tracheostomy include upper airway obstruction (e.g., obstructive sleep apnea; stridor … to head/neck surgery or trauma. 4 The benefits of tracheostomy, compared with endotracheal tubes, include … endotracheal tubes before tracheostomy. 8 Modifiable care-related risk factors for tracheal fistulas include … broader hospital standards. 13,14 Tracheostomy teams can be structured in different ways and often include … Policy and staff education should include airway cuff pressure monitoring technique and protocols.
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - addition, there are several suspected diagnoses that require urgent
evaluation and imaging; these include … – These include new urinary retention, fecal incontinence, saddle anesthesia,
history of intravenous … factors outside the control of the
physician or the healthcare system
– System-related errors, which include … technological or organizational
barriers
– Cognitive errors, which include inadequate knowledge, poor … Tactics to prevent pain management from becoming
adversarial include early and frequent communication
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psnet.ahrq.gov/node/855000/psn-pdf
November 01, 2023 - Topics discussed include team dynamics, operating room design, and high reliability.
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psnet.ahrq.gov/node/861295/psn-pdf
January 24, 2024 - Factors contributing to her
death include delayed recognition of deterioration, and communication failures
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psnet.ahrq.gov/node/38269/psn-pdf
October 01, 2024 - nursing-home-survey-patient-safety-culture
Challenges to establishing and sustaining a safety culture in a nursing home include
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psnet.ahrq.gov/node/867696/psn-pdf
March 05, 2025 - Topics include the importance of understanding failure to
rescue, the patient’s role in care escalation
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psnet.ahrq.gov/node/864352/psn-pdf
March 13, 2024 - Strategies include creating an accessible reporting
system, implementation of a "good catch" program
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psnet.ahrq.gov/node/34114/psn-pdf
September 20, 2023 - Topics covered include safe surgery, pain management,
medication safety, and most recently, how preventive
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psnet.ahrq.gov/node/42075/psn-pdf
February 27, 2020 - Areas of focus include leadership, medication safety expertise,
change management, research and education
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psnet.ahrq.gov/node/47966/psn-pdf
May 29, 2019 - Featured tools include the Situation-Background-Assessment-Recommendation approach,
huddle agendas,
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psnet.ahrq.gov/node/72536/psn-pdf
December 02, 2020 - They include
automation failures, the role of the obstetric anesthesiologist in maternal safety, and
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psnet.ahrq.gov/node/50648/psn-pdf
November 06, 2019 - Systemic factors contributing to the
problem discussed include medications produced by a single supplier
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psnet.ahrq.gov/node/60311/psn-pdf
May 06, 2020 - Strategies discussed
to address the problem include medication, cognitive therapies and personal wellness
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psnet.ahrq.gov/node/36146/psn-pdf
February 05, 2019 - https://psnet.ahrq.gov/issue/guidelines-design-and-construction
These updated guidelines include design
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psnet.ahrq.gov/node/47915/psn-pdf
April 03, 2019 - The authors suggest that regulatory review of devices that employ machine learning
include an assessment
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psnet.ahrq.gov/node/60189/psn-pdf
April 01, 2020 - The recommendations include prescription review,
issue awareness, point-of-care information access,
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psnet.ahrq.gov/node/858325/psn-pdf
December 13, 2023 - Improvement strategies
discussed include patient education, practitioner coaching and interpreter services
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Recommendations for improvement include examining electronic health record alerts, assigning
one prescriber
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - with up to one-third of these errors leading to observed patient harm. 2,3 The most common errors include … with a way to examine their medication safety practices, and The Joint Commission (TJC) continues to include … Common strategies to differentiate between products (i.e. look-alike sound-alike medications) include … Solutions may vary but can include documenting waste via automated dispensing cabinets or directly in … Challenges include but are not limited to 16
Decreased access to clinical decision support tools
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - quitting or replacing smoking with a less harmful nicotine delivery system.( 3,4 ) The potential risks include … the US, the use of e-cigarettes is prohibited wherever smoking tobacco is not allowed, which would include … Public Health England recommendations include the use of e-cigarettes to support tobacco control policies … Most hospitals in the United States include e-cigarettes in smoke-free policies that were developed for … Where smoke-free policies include banning the use of e-cigarettes, all cigarette smokers and e-cigarette