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1481. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
      January 01, 2023 - Workplace culture and human resource availability are common barriers to best practices. … Improving Patient Safety: Equipment and Resource Preparation (1) • Procedural sedation requires not just … • Numerous barriers to reporting exist including fear of consequences, a culture of blame, perception … errors in a user-friendly and non-punitive manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors

1482. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - Workplace culture and human resource availability are common barriers to best practices To understand … hospitalization because of a SAE. 23 Equipment and resource preparation Procedural sedation requires not just … Numerous barriers to reporting exist including fear of consequences, a culture of blame, perception … errors in a user-friendly and non-punitive manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors

1483. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet
      psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
      November 25, 2020 - counts and either high or moderate bandemia, respectively, bandemia was associated with positive blood cultures … Same Author(s) WebM&M Cases Premature Closure: Was It Just

1484. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33745/psn-pdf
      February 01, 2013 - In just the past few months, the Commonwealth Fund reported a striking degree of international variation

1485. Empty Handoff | PSNet
      psnet.ahrq.gov/web-mm/empty-handoff
      August 01, 2017 - Just as the success of a handoff must be considered along multiple dimensions, so should improvements … contributions built into the discussions Threat & Error Management Reliability established in safe cultures

1486. Breakage of a PICC Line | PSNet
      psnet.ahrq.gov/web-mm/breakage-picc-line
      June 21, 2023 - Cultures taken via blood and PICC reported moderate growth of Staphylococcus . … The tip of the central venous catheter (CVC) should be just above the superior vena cava/right atrium

1487. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
      psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
      September 27, 2023 - Imaging plays an important role in the detection of foreign material, not just identification of fractures … blunt injury involve greater tissue damage invisible to the naked eye and these wounds require not just … opposed to penetrating injuries—frequently involve tissue damage and devitalization, which is simply culture

1488. Code Status vs. Care Status | PSNet
      psnet.ahrq.gov/web-mm/code-status-vs-care-status
      September 30, 2020 - choices, a provider should check the patient’s understanding by asking them to explain what they have just … a knowledge gap that we fill with our own explanation, informed by our own experiences, values, and beliefs … high burnout among nurses, further stressing their limited resources. 24  In this case, it was not just … Medication September 30, 2020 WebM&M Cases Culture

1489. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks | PSNet
      psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
      September 01, 2017 - patient was in her 30’s, she went through a period of significant emotional and financial stress, having just … comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture

1490. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - One study found that when comparing 12 months of data from just prior to the pandemic to six months of … KH: Just to clarify—you are able to capture whether the event was related to COVID-19, but that doesn't … When, typically, staff would just use one N95 mask per patient, per time, now they had to decontaminate … October 24, 2021 Perspectives on Safety Safety Culture

1491. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49522/psn-pdf
      November 01, 2006 - heart failure or pulmonary embolism.(11) While less apparent, the problem of indirect harm may be just … was in fact no such reporting requirement, and the attending physician was not correct in his or her belief … Oxygenation Assessment Initial Antibiotic Timing Pneumococcal Vaccination Influenza vaccination Blood culture

1492. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846769/psn-pdf
      March 29, 2023 - She was diagnosed as having either “mono-spot negative mononucleosis” or “culture-negative and ASO-negative … https://psnet.ahrq.gov/primer/diagnostic-errors https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope

1493. Medication Mix-Up: From Bad to Worse | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-bad-worse
      March 01, 2018 - Notably, the near miss in the current case took place at an institution just prior to its conversion … April 24, 2018 Exploring safety culture within inpatient mental health units: the results

1494. Spinal Epidural Abscess | PSNet
      psnet.ahrq.gov/web-mm/spinal-epidural-abscess
      November 13, 2019 - Clinicians should use their judgment and just keep a high suspicion for the diagnosis in patients with … systems should facilitate more effective teamwork in the diagnostic process as well as establish a culture

1495. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet
      psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
      November 15, 2023 - April 20, 2022 Fostering a just culture in healthcare organizations: experiences in practice

1496. Care Transitions | PSNet
      psnet.ahrq.gov/perspective/care-transitions
      December 01, 2007 - I would argue that a good hospital discharge transition is just as important as a thorough admission … coming in for follow-up, only for them to berate me about the terrible episode of care that they had just … Then there's a series of two or three phone calls after that, just to see how things went and whether

1497. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
      psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
      October 01, 2004 - heart failure or pulmonary embolism.( 11 ) While less apparent, the problem of indirect harm may be just … was in fact no such reporting requirement, and the attending physician was not correct in his or her belief … Oxygenation Assessment Initial Antibiotic Timing Pneumococcal Vaccination Influenza vaccination Blood culture

1498. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
      April 29, 2020 - She was admitted for work-up including a COVID-19 test, viral panel, urinalysis, and blood cultures – … case, a follow-up visit using video technology was appropriate, as the patient had been discharged just

1499. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73103/psn-pdf
      March 31, 2021 - She was admitted for work-up including a COVID-19 test, viral panel, urinalysis, and blood cultures … case, a follow-up visit using video technology was appropriate, as the patient had been discharged just

1500. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861838/psn-pdf
      January 31, 2024 - Just as with IVR-type technology, a host of vendors have solutions that can work with health systems