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psnet.ahrq.gov/issue/simulation-based-trial-surgical-crisis-checklists
July 25, 2011 - Although these critical surgical events are relatively common in large hospitals, they are rare for individual … July 25, 2011
Pilot testing of a model for insurer-driven, large-scale multicenter simulation
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psnet.ahrq.gov/issue/active-surveillance-using-electronic-triggers-detect-adverse-events-hospitalized-patients
October 03, 2017 - The authors discuss the large percentage of preventable adverse events that were discovered along with … 2017
Using an electronic prescribing system to ensure accurate medication lists in a large
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psnet.ahrq.gov/node/44896/psn-pdf
March 23, 2016 - https://psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based … https://psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
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psnet.ahrq.gov/node/43333/psn-pdf
January 15, 2017 - multidisciplinary, multifaceted improvement initiative to
eliminate mislabelled laboratory specimens at a large … multidisciplinary, multifaceted improvement initiative to eliminate
mislabelled laboratory specimens at a large
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psnet.ahrq.gov/node/42105/psn-pdf
June 28, 2013 - A prior Australian study discusses methods used for mass
notification of patients after a large-scale … patient-notification-bloodborne-pathogen-testing-due-unsafe-injection-practices-us-health
https://psnet.ahrq.gov/issue/look-back-and-talk-openly-responding-and-communicating-about-risk-large-scale-error-pathology
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psnet.ahrq.gov/node/61037/psn-pdf
January 01, 2021 - reporting-patient-safety-events
https://psnet.ahrq.gov/issue/frequency-diagnostic-errors-outpatient-care-estimations-three-large-observational-studies … https://psnet.ahrq.gov/issue/frequency-diagnostic-errors-outpatient-care-estimations-three-large-observational-studies
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psnet.ahrq.gov/node/844801/psn-pdf
January 01, 2021 - This mixed-methods study of a large-scale improvement program
in the United Kingdom provides important … Measurement was a challenge for all sites, attributed in large part to frontline
staff's lack of experience
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - Major surgical procedures, including craniotomy,
require large-bore venous access in case of rapid and … Complex surgeries usually require at least two large-bore intravenous catheters,
with 22-gauge catheters … infusion of fluids is anticipated.2 Common sites for large-bore catheters
in infants include the saphenous … clear securement devices as well as frequent intravenous catheter assessments prior to and during
large … an intravenous catheter is inversely proportional to the length of the
tubing; therefore, a short large-bore
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psnet.ahrq.gov/node/41546/psn-pdf
December 29, 2014 - using-logic-model-design-and-evaluate-quality-and-patient-safety-
improvement-programs
Discussing an approach that helped guide project management of a large-scale … infections, this commentary details how such an approach can be applied to plan,
implement, and evaluate large-scale
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - Spotlight
Spotlight
Missing a Large Vessel Occlusion Stroke in
a Patient with a History of Seizures … access to subspecialty services for patients in rural and
underserved communities.
3
MISSING A LARGE … for intravenous
thrombolysis in acute ischemic stroke and, more recently,
endovascular therapy for large … cerebral artery (MCA) strokes (i.e.,
LVOs), in which specialized catheters are deployed within the large … CT perfusion
demonstrates a large
area of right middle
cerebral artery territory
brain tissue at
-
psnet.ahrq.gov/node/45068/psn-pdf
August 15, 2017 - strokes were initially
misdiagnosed in the emergency departments of an academic teaching hospital and a large … https://psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
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psnet.ahrq.gov/issue/quality-performance-improvement-teamwork-information-technology-and-protocols
November 03, 2015 - Related Resources From the Same Author(s)
Intended and unintended effects of large-scale … adverse event disclosure: a controlled before-after analysis of five large-scale notifications. … Impact of pharmacist-led discharge medication reconciliation on error and patient harm prevention at a large
-
psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
June 12, 2019 - be very strong evidence that going through a checklist before a surgical procedure could create very large … Yet a checklist that confirms the use of these various maneuvers by itself seemed to show a very large … Our findings are inconsistent with benefits as large as those suggested by earlier studies. … It's not as easy to get a large number of subjects and independent pieces of information with which to … They're great additions to what we do, but I am skeptical that they result in these strikingly large
-
psnet.ahrq.gov/node/41839/psn-pdf
November 27, 2012 - approach to the identification and
classification of near-miss events on labor and delivery in
a large … approach to the identification and classification of near-
miss events on labor and delivery in a large
-
psnet.ahrq.gov/node/46099/psn-pdf
May 31, 2017 - /primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
https://psnet.ahrq.gov/issue/large-scale-implementation-i-pass-handover-system-academic-medical-centre … https://psnet.ahrq.gov/issue/large-scale-implementation-i-pass-handover-system-academic-medical-centre
-
psnet.ahrq.gov/node/44043/psn-pdf
September 20, 2017 - in pursuit of high reliability:
implementing a comprehensive, low-threshold reporting
program in a large … in pursuit of high reliability: implementing a
comprehensive, low-threshold reporting program in a large
-
psnet.ahrq.gov/node/46911/psn-pdf
May 02, 2018 - health record–based data query of
statin prescriptions in patients with coronary artery
disease in a large … Health Record-Based Data Query of Statin
Prescriptions in Patients With Coronary Artery Disease in a Large
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psnet.ahrq.gov/issue/cultural-and-associated-enablers-and-barriers-adverse-incident-reporting
March 23, 2011 - June 14, 2011
Attitudes toward the large-scale implementation of an incident reporting … A case study from a large metropolitan healthcare trust. … September 1, 2011
Attitudes toward the large-scale implementation of an incident reporting
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psnet.ahrq.gov/issue/navigating-towards-improved-surgical-safety-using-aviation-based-strategies
January 04, 2011 - February 12, 2020
Medical large language models are vulnerable to data-poisoning attacks … November 16, 2022
Use of nondisclosure agreements in medical malpractice settlements by a large … December 21, 2014
Pilot testing of a model for insurer-driven, large-scale multicenter
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psnet.ahrq.gov/issue/role-chief-executive-officers-quality-improvement-qualitative-study
September 17, 2014 - December 29, 2014
Perceptions of the impact of a large-scale collaborative improvement … Culture and behaviour in the English National Health Service: overview of lessons from a large … December 6, 2010
Perceptions of the impact of a large-scale collaborative improvement