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The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition. | PSNet

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May 12, 2010 - systems thinking” literature in patient safety, such as Leape’s classic 1994 Journal of the American Medical … February 8, 2011 Medical errors disclosure and apology. … October 24, 2018 A National Trauma Care System: Integrating Military and Civilian Trauma … Systems to Achieve Zero Preventable Deaths After Injury.

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. | PSNet

psnet.ahrq.gov/issue/medical-malpractice-lawsuits-involving-trainees-obstetrics-and-gynecology-usa

February 15, 2023 - Study Medical malpractice lawsuits involving trainees in obstetrics and gynecology … Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. … Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and … Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA.

Developing and evaluating large language model-generated emergency medicine handoff notes. | PSNet

psnet.ahrq.gov/issue/developing-and-evaluating-large-language-model-generated-emergency-medicine-handoff-notes

March 12, 2025 - RIS Download Citation Related Resources From the Same Author(s) Medical … September 1, 2016 A randomized trial of a multifactorial strategy to prevent serious fall injuries … July 29, 2020 WebM&M Cases Missing the Point—Eye Injury … from emergency department to inpatient care: a cross-sectional survey of physicians at a university medical

The Unfamiliar Catheter | PSNet

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November 01, 2006 - devastating patient injury and secondary emotional trauma for the involved health care professional. … The guidance is intended to improve the usability of medical devices to reduce user error, injuries from … Take-Home Points Unfamiliarity with a CVC can lead to a serious patient injury and have a profound … Medical device related deaths and injuries should be reported to the FDA . … July 19, 2023 Implementation of the World Health Organization Trauma Care Checklist Program

Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? | PSNet

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April 27, 2022 - Since they are considered non-medical facilities, they are not required to have nurses, certified nursing … this case a Hoyer lift, that would not only enhance safe patient care but also help to prevent staff injury … In California, administrators report using the LIC 624 Unusual Incident/Injury Report form , 8 which … two-person assistance by themselves, the facility will more likely be cited for deficiency especially if an injury … Lic 624 – Unusual Incident/Injury Report .

Potentially inappropriate medications according to STOPP-J criteria and risks of hospitalization and mortality in elderly patients receiving home-based medical services | PSNet

psnet.ahrq.gov/issue/potentially-inappropriate-medications-according-stopp-j-criteria-and-risks-hospitalization

January 27, 2021 - STOPP-J criteria and risks of hospitalization and mortality in elderly patients receiving home-based medical … STOPP-J criteria and risks of hospitalization and mortality in elderly patients receiving home-based medical … This 5-year prospective cohort study of 196 elderly patients receiving home-based medical services in … July 22, 2020 System approach to prevent common bile duct injury and enhance performance … March 3, 2019 Discrepancies between in-home interviews and electronic medical records

A simple surgery with harrowing complications. | PSNet

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November 07, 2012 - Citation Related Resources From the Same Author(s) Death of a boy prompts new medical … August 5, 2008 Doctors could learn something about medical handoffs from the Navy. … July 10, 2013 Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy … March 29, 2012 Family of woman who died after a medical error joins hospital's safety … October 19, 2011 Role of intraoperative cholangiography in avoiding bile duct injury.

Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet

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January 29, 2021 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … ; this change was associated with decreased risk of motor vehicle crash involvement and needlestick injury … Errors as well as needle stick injuries increased threefold when nurses worked shifts exceeding 12 hours … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours?

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit. | PSNet

psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older

April 20, 2022 - Study Clinical characteristics and short-term outcomes of acute kidney injury missed … Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients … cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury … Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients

Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. | PSNet

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January 27, 2021 - Classic Assessment of physician sleep and wellness, burnout, and clinically significant medical … Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. … Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. … November 16, 2022 A randomized trial of a multifactorial strategy to prevent serious fall injuries … September 7, 2022 Does seasonal variation in orthopaedic trauma volume correlate with

Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator. | PSNet

psnet.ahrq.gov/issue/positive-predictive-value-ahrq-accidental-puncture-or-laceration-patient-safety-indicator

April 03, 2017 - The AHRQ Patient Safety Indicator accurately identified accidental injuries due to medical care, but … 2015 Beating the weekend trend: increased mortality in older adult traumatic brain injury … View More See More About The Topic Hospitals Quality and Safety Professionals Medical

"Recurrent" Appendicitis | PSNet

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January 15, 2020 - The surgeon had recently joined the medical staff after completing a general surgery residency and then … The Commentary This case provides an opportunity to review two important issues in surgery: (i) medical … in the elderly compared to approximately 20% in the general population).( 2,3,6 ) The most common medical … If a laparoscopic approach is used, there is the additional risk of injury during trocar (the port used … Greenberg, MD, MPH Assistant Professor of Surgery, Harvard Medical School Director, Center for

Woman works to end Black maternal health crisis after daughter dies after giving birth. | PSNet

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May 27, 2020 - Maternal injury is a persistent challenge in the Black community . … Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma … January 27, 2009 Take Charge of Your Hospital Stay to Avoid Medical Mistakes.

Haste Makes Care Unsafe | PSNet

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January 07, 2015 - Catheter insertion can result in arterial injury and related hematomas, hemopneumothorax, and dangerous … In a medical care setting, a critical care handover formal checklist can be completed rapidly when necessary … Importantly, experience teaches that it takes only one patient save in which an impending injury was … January 7, 2015 Standards for patient monitoring during general anesthesia at Harvard Medical … Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical

The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours. | PSNet

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October 14, 2015 - A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical … Association of implementation and social network factors with patient safety culture in medical … January 26, 2022 Association of low-dose whole-body computed tomography with missed injury … diagnoses and radiation exposure in patients with blunt multiple trauma. … October 6, 2011 Development of a modified early warning score using the electronic medical

Department of Defense Health Care Quality. | PSNet

psnet.ahrq.gov/issue/department-defense-health-care-quality

February 11, 2025 - care program in including culture of safety development, error and near miss report analysis, and medical … November 16, 2011 VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. | PSNet

psnet.ahrq.gov/issue/estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-medical-and-surgical

July 11, 2018 - Estimating the economic cost of nurse sensitive adverse events amongst patients in medical … Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical … Some adverse events are sensitive to aspects of nursing care , including pressure injuries , falls, … Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries

Associations between in-hospital mortality, health care utilization, and inpatient costs with the 2011 resident duty hour revision. | PSNet

psnet.ahrq.gov/issue/associations-between-hospital-mortality-health-care-utilization-and-inpatient-costs-2011

June 09, 2021 - In 2011, the Accreditation Council for Graduate Medical Education made changes to resident duty hours … June 9, 2021 Nursing interruptions in a trauma intensive care unit: a prospective observational … July 6, 2011 Effects of the Accreditation Council for Graduate Medical Education duty … February 24, 2011 Association of workload of on-call medical interns with on-call sleep … February 3, 2011 Decreased bile duct injury rate during laparoscopic cholecystectomy

Emergency department crowding and risk of preventable medical errors. | PSNet

psnet.ahrq.gov/issue/emergency-department-crowding-and-risk-preventable-medical-errors

November 23, 2011 - Study Emergency department crowding and risk of preventable medical errors. … Emergency department crowding and risk of preventable medical errors. … Emergency department crowding and risk of preventable medical errors. … January 26, 2022 Safety climate and medical errors in 62 US emergency departments. … September 30, 2020 Surgeon commitment to trauma care decreases missed injuries.

The impact of the 80-hour work week on appropriate resident case coverage. | PSNet

psnet.ahrq.gov/issue/impact-80-hour-work-week-appropriate-resident-case-coverage

June 18, 2008 - June 26, 2024 Temporal clustering of critical illness events on medical wards. … August 11, 2010 Framing family conversation after early diagnosis of iatrogenic injury … May 4, 2010 Impact of the Accreditation Council for Graduate Medical Education work-hour … May 20, 2009 Decreased bile duct injury rate during laparoscopic cholecystectomy in the

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