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psnet.ahrq.gov/issue/anesthesiology-department-leads-culture-change-hospital-system-level-improve-quality-and
March 30, 2011 - Commentary
An anesthesiology department leads culture change at a hospital system … An anesthesiology department leads culture change at a hospital system level to improve quality and patient … An anesthesiology department leads culture change at a hospital system level to improve quality and patient
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an … Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an … Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an … Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an
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psnet.ahrq.gov/node/837308/psn-pdf
June 01, 2022 - delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery … https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
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psnet.ahrq.gov/print/pdf/node/867659
July 10, 2024 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. … delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
By Gary S. … https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
https
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psnet.ahrq.gov/node/42535/psn-pdf
October 16, 2013 - Implementing an interprofessional patient safety learning
initiative: insights from participants, project leads … Implementing an interprofessional patient safety learning initiative:
insights from participants, project leads
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psnet.ahrq.gov/node/43661/psn-pdf
November 05, 2014 - challenging-authority-during-life-threatening-crisis-effect-operating-theatre-hierarchy
https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error … https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error
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psnet.ahrq.gov/node/47616/psn-pdf
August 14, 2019 - The authors theorized that misalignment leads to missed follow-up testing and deterioration in
patient–physician … issue/process-care-failures-breast-cancer-diagnosis
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - CME/MOC
Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads … Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and … Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and … Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and
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psnet.ahrq.gov/issue/safety-still-compromised-computer-weaknesses
September 14, 2016 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared … August 24, 2016
Misprogramming PCA concentration leads to dosing errors. … July 17, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads
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psnet.ahrq.gov/node/47441/psn-pdf
September 26, 2018 - patient-outcomes-after-introduction-statewide-icu-nurse-staffing-regulations
Inadequate nurse staffing in hospitals leads … reassessment, which are particularly important for
seriously ill patients, and that inadequate staffing leads
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - .
– The anesthesia resident had only connected ECG leads into the anesthesia monitor, and not
into … )
may be induced by attempted cardioversion.8
– It is therefore very important to connect the ECG leads … pacing mode, as in the electrophysiology lab or in the operating room, where
pacing via epicardial leads … – With this set-up, a separate pair of chest leads directly connected to the defibrillator
is no … (1)
Connect defibrillators to the ECG leads (2)
Connect defibrillators to the ECG leads (3)
Be familiar
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - While a standard diagnostic ECG acquires data from 12 different leads (via 10 electrodes placed on the … could have checked the patient's full diagnostic
standard 12-lead ECG to determine which of the 12 leads … Another suggestion for industry is to create
algorithms that analyze all of the available ECG leads, … rather than only a select few leads. … Low voltage QRS complexes are present in the seven leads available for
monitoring (I, II, III, aVR,
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without … Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without … Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without … Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - often monitored using telemetry
A standard electrocardiogram (ECG) acquires data from 12 different leads … Telemetry monitoring is a 5-electrode configuration
Acquires 6 limb leads (I, II, III, aVR, aVL, aVF … ) and
1 chest lead (V)
Telemetry display usually only shows 2 leads (often leads II and V)
A computer … algorithm then continuously analyzes a limited number of leads (usually 1–2)
The algorithm monitors … 19
Device Settings to Combat Alarm Fatigue (2)
Creating algorithms that analyze all available ECG leads
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psnet.ahrq.gov/issue/pharmacy-mixes-prescriptions
March 10, 2021 - Pharmacy error leads to fatal medication mix-up. … Pharmacy error leads to fatal medication mix-up.
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psnet.ahrq.gov/issue/patient-outcomes-after-introduction-statewide-icu-nurse-staffing-regulations
June 19, 2019 - Inadequate nurse staffing in hospitals leads to increased morbidity and mortality . … reassessment, which are particularly important for seriously ill patients , and that inadequate staffing leads
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - While a standard diagnostic ECG acquires data from 12 different leads (via 10 electrodes placed on the … patient's body), telemetry monitoring systems typically acquire data from fewer leads (via 3–6 electrodes … could have checked the patient's full diagnostic standard 12-lead ECG to determine which of the 12 leads … Another suggestion for industry is to create algorithms that analyze all of the available ECG leads, … rather than only a select few leads.
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psnet.ahrq.gov/training-catalog/2022-hqi-annual-conference
January 01, 2022 - professionals in attendance will highlight successes, celebrating achievements, and charting a course that leads
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psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-intermittent
December 14, 2022 - October 20, 2021
Leaving a discontinued FentaNYL infusion attached to the patient leads … October 21, 2020
Incorrect use of smart infusion pump in the operating room (OR) leads
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. … A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018. … https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented … https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Commentary
by Christopher … Leads the World in Health
Expenditures. New York Times. June 1, 2013. [Available at]
14. Cooke M.