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psnet.ahrq.gov/issue/tennessee-center-patient-safety
May 03, 2023 - June 15, 2016
Evidence-based Recommendations for Best Practices in Weight Loss Surgery
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psnet.ahrq.gov/issue/diagnostic-errors-primary-care
May 03, 2023 - June 15, 2016
Evidence-based Recommendations for Best Practices in Weight Loss Surgery
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - At the time, the primary care doctor documented 4/5 weakness in all extremities and a loss of sensation … Based on this, the patient was diagnosed with a peripheral neuropathy (a loss of sensation that typically … Neurologic Exam (2)
Reflexes
Biceps, brachioradialis
Knees, Achilles
Sensory
Assess for patterns of sensory loss
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psnet.ahrq.gov/node/41317/psn-pdf
January 31, 2013 - effect-comprehensive-surgical-safety-system-patient-outcomes
https://psnet.ahrq.gov/issue/38-year-old-woman-fetal-loss-and-hysterectomy
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psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
August 31, 2022 - In addition, because patients with multiple sclerosis can experience neurological deficits due to loss … of myelin and axons, this pathology often resulting in loss of vision, paralysis, sensory loss, ataxia … , adverse brainstem signs, psychiatric disorders, and dementia, 3 any sensory loss or neurological deficits … positioning the camera or mobile device for adequate visualization of the area of concern. 5 Fear of loss
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psnet.ahrq.gov/issue/critical-supply
June 16, 2019 - November 29, 2009
Insurers' Medical Loss Ratios and Quality Improvement Spending in 2011
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psnet.ahrq.gov/issue/preventing-adverse-events-cataract-surgery-recommendations-massachusetts-expert-panel
July 16, 2019 - In 2016, five patients undergoing routine cataract surgery developed irreversible visual loss during
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psnet.ahrq.gov/issue/dual-surgeon-operating-improve-patient-safety
July 22, 2020 - , non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss
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psnet.ahrq.gov/issue/organisational-strategies-implement-hospital-pressure-ulcer-prevention-programmes-findings
June 02, 2021 - Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment
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psnet.ahrq.gov/issue/pediatric-faculty-knowledge-and-comfort-discussing-diagnostic-errors-pilot-survey-understand
April 22, 2020 - respondents expressed discomfort discussing diagnostic errors in public settings, citing fear regarding loss
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psnet.ahrq.gov/node/42068/psn-pdf
April 09, 2013 - wisdom-through-adversity-learning-and-growing-wake-error
Clinicians who commit a medical error experience a wide range of emotional responses, including loss
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psnet.ahrq.gov/node/38075/psn-pdf
February 03, 2011 - intern workload and discovered that increased responsibilities were associated with greater sleep loss
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psnet.ahrq.gov/node/33577/psn-pdf
September 07, 2019 - differences in mortality, complications, or readmissions between procedures
performed by surgeons with sleep loss … compared to those without sleep loss.
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psnet.ahrq.gov/issue/double-booked-when-surgeons-operate-two-patients-once
March 29, 2017 - This news article reports on concurrent procedures, how double-booking can result in loss of trust
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - navigational bronchoscopy with transbronchial biopsy for evaluation of
lymphadenopathy, cough, and weight loss … patients finding 89.7% of these patients had minimal bleeding (<5ml), 8.1% had mild (5-20 ml) blood
loss … , and 2.1% had moderate (20-100 ml) of blood loss.3
Iatrogenic pneumothorax is a known and feared complication … Blood loss during flexible bronchoscopy:
aprospective observational study.
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - Quality Initiative (KDOQI), 1 this patient suffered a completely avoidable complication of guidewire loss … patient. 13 In the great majority of these and other cases (albeit not the case reported here), 14,15 loss … Loss of the guide wire: mishap or blunder? … The human error: delayed diagnosis of intravascular loss of guidewires for central venous catheterization
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psnet.ahrq.gov/node/44278/psn-pdf
July 01, 2015 - When doctors don't talk to doctors.
July 1, 2015
Bond A.
https://psnet.ahrq.gov/issue/when-doctors-dont-talk-doctors
Clinician communication with patients and families during transitions has been a focus of safety
improvement efforts. This newspaper article describes insights from a resident physician regarding ho…
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psnet.ahrq.gov/issue/massachusetts-alliance-communication-and-resolution-following-medical-injury
May 03, 2023 - June 15, 2016
Evidence-based Recommendations for Best Practices in Weight Loss Surgery
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psnet.ahrq.gov/issue/voices-frontlines-health-care-safety
May 03, 2023 - April 3, 2019
Evidence-based Recommendations for Best Practices in Weight Loss Surgery
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psnet.ahrq.gov/node/43074/psn-pdf
December 18, 2014 - They describe the incremental loss of the traditional model of graded autonomy for residents
and point