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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - underreporting of vascular injury. … How can this type of injury be prevented? … Three spectra of laparoscopic entry access injuries. … Major vascular injuries during laparoscopic
procedures. … Improving continuing medical education for surgical techniques:
applying the lessons learned in the
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psnet.ahrq.gov/issue/symposium-simulation-science-health-and-medicine
April 03, 2017 - J Emerg Trauma Shock. 2010;3:348-394. … March 23, 2022
High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients. … February 17, 2021
Zero preventable deaths after traumatic injury: an achievable goal. … April 6, 2011
Medical Errors and Safety Systems.
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - for similar patients would consider possibilities such
as cervical spine fractures, hypoxic brain injury … , vascular injury, stroke, airway trauma, and asystolic
cardiac arrest secondary to carotid baroreceptor … Evidence of airway trauma, manifesting as stridor,
difficulty speaking (dysphonia), or painful swallowing … Similarly, cervical spine fractures, hypoxic
brain injury, and vascular (e.g., carotid artery, vertebral … .10 These high-risk injuries make medical
clearance for psychiatric confinement impossible in the near
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psnet.ahrq.gov/issue/patient-complaints-and-malpractice-risk
November 08, 2013 - A retrospective review of 645 physicians in a large U.S. medical group was performed. … February 16, 2011
A randomized trial of a multifactorial strategy to prevent serious fall injuries … July 29, 2020
Improving reconciliation following medical injury: a qualitative study … April 14, 2011
Claiming behaviour in a no-fault system of medical injury: a descriptive
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psnet.ahrq.gov/issue/whats-past-prologue-organizational-learning-serious-patient-injury
October 26, 2011 - Study
What’s past is prologue: organizational learning from a serious patient injury … What’s past is prologue: Organizational learning from a serious patient injury. … What’s past is prologue: Organizational learning from a serious patient injury. … November 16, 2022
Medical large language models are vulnerable to data-poisoning attacks … 2011
Association of open communication and the emotional and behavioural impact of medical
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psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Other examples of injuries due to acute acid–base irritation are those caused by topical applications … , as demonstrated by this case, such injuries continue to occur. … It may be that the extent of the injury in this case was underestimated because of the small area of … uncertain state of the evidence regarding neutralization and other maneuvers to avoid skin irritant injuries … Chemical Skin Injury: Mechanisms, Prevention, Decontamination, Treatment.
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psnet.ahrq.gov/issue/incidence-and-prevention-iatrogenic-urethral-injuries
August 02, 2015 - Study
Incidence and prevention of iatrogenic urethral injuries. … Incidence and prevention of iatrogenic urethral injuries. … Approximately 1 in 300 male patients at this university hospital experienced a urethral injury due to … A nursing education program significantly reduced the risk of injury. … Incidence and prevention of iatrogenic urethral injuries.
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psnet.ahrq.gov/issue/preventable-errors-operating-room-part-2-retained-foreign-objects-sharps-injuries-and-wrong
April 25, 2018 - Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries … September 24, 2017
Medical errors related to discontinuity of care from an inpatient … More
Related Resources
Identifying resilience: a system safety review of trauma … DeBakey VA Medical Center in Houston, Texas. … Investigation of urology intraoperative events leading to root cause analysis at national VA medical
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psnet.ahrq.gov/issue/optimizing-patient-handoff-between-ems-and-emergency-department
April 24, 2018 - Optimizing the patient handoff between emergency medical services and the emergency department. … Optimizing the patient handoff between emergency medical services and the emergency department. … April 12, 2019
Addressing prehospital patient safety using the science of injury prevention … August 9, 2023
High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients.
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psnet.ahrq.gov/issue/inappropriate-prescribing-older-patients-nurse-practitioners-and-primary-care-physicians
September 23, 2020 - Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury … March 3, 2011
Patterns of communication breakdowns resulting in injury to surgical patients … December 22, 2010
Disclosure of medical injury to patients: an improbable risk management … May 20, 2015
Claims, errors, and compensation payments in medical malpractice litigation
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - In rare circumstances, significant hypoperfusion with ischemic injury to the calf
muscles may result … Early evaluation and fasciotomy by an orthopedic or trauma surgeon are key to preventing
permanent injury … of Anesthesiology and Pain Medicine
UC Davis Health
chbohringer@ucdavis.edu
Gustavo Chavez, MD
Medical … Int Wound J. 2008;5(2):315-328. [Free full
text]
6. Matsen FA 3rd. … Prevention of well-leg compartment syndrome following lengthy
medical operations in the lithotomy position
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psnet.ahrq.gov/issue/reducing-falls-hospitalized-children-and-adolescents-cancer-and-blood-disorders-quality
November 16, 2022 - Falls with injury are a never event. … physical therapy to reduce deconditioning, and completion of apparent cause analysis for all falls with injury … postdischarge incidents after implementation of a hospital-to-home transition intervention for children with medical … October 4, 2023
Medical large language models are vulnerable to data-poisoning attacks … April 11, 2011
Medical injuries among hospitalized children.
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psnet.ahrq.gov/issue/institute-medicine-report-medical-errors-could-it-do-harm
February 18, 2011 - The Institute of Medicine report on medical errors--could it do harm? … He also notes the discordance between the demand for systematic approaches to injury prevention and the … The Institute of Medicine report on medical errors--could it do harm? … Results of the Harvard Medical Practice Study I. … February 18, 2011
Preventing medical injury.
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psnet.ahrq.gov/node/37327/psn-pdf
March 03, 2011 - Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury … Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury … psnet.ahrq.gov/issue/patterns-technical-error-among-surgical-malpractice-claims-analysis-
strategies-prevent-injury … psnet.ahrq.gov/issue/patterns-technical-error-among-surgical-malpractice-claims-analysis-strategies-prevent-injury … https://psnet.ahrq.gov/issue/claims-errors-and-compensation-payments-medical-malpractice-litigation
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psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
March 03, 2011 - Classic
Patterns of communication breakdowns resulting in injury … Patterns of communication breakdowns resulting in injury to surgical patients. … Patterns of communication breakdowns resulting in injury to surgical patients. … Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury … 21, 2014
Surgical case listing accuracy: failure analysis at a high-volume academic medical
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - The patient subsequently underwent surgical repair of the
tracheal injury. … obstruction (e.g., obstructive sleep apnea; stridor and air hunger due
to vocal cord paralysis or neck trauma … intubate, ventilatory support for neuromuscular disease, and as an adjunct to
head/neck surgery or trauma … preventable
through careful procedural and post-placement care.6
Patient-related risk factors that affect wound … absent capillary blood flow at
cuff pressures over 50 cm H20.15 Stenosis, fistulas, and other tracheal injuries
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psnet.ahrq.gov/issue/violations-behavioral-practices-revealed-closed-claims-reviews
August 26, 2011 - Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … October 12, 2009
A randomized trial of a multifactorial strategy to prevent serious fall injuries … July 29, 2020
Changes in medical errors after implementation of a handoff program. … August 11, 2010
Framing family conversation after early diagnosis of iatrogenic injury … February 25, 2009
Laparoscopic bile duct injury: understanding the psychology and heuristics
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psnet.ahrq.gov/issue/heart-health-care-parents-perspectives-patient-safety
April 24, 2018 - December 19, 2018
Assessing patients 2019 experiences with medical injury reconciliation … injury. … injury. … November 15, 2018
A framework for encouraging patient engagement in medical decision … November 21, 2016
Insensible losses: when the medical community forgets the family.
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - reserved for those patients with immediately life-threatening conditions like cardiac arrest, blunt trauma … , vascular injury, stroke, airway trauma, and asystolic cardiac arrest secondary to carotid baroreceptor … Similarly, cervical spine fractures, hypoxic brain injury, and vascular (e.g., carotid artery, vertebral … . 10 These high-risk injuries make medical clearance for psychiatric confinement impossible in the near … Non-fatal strangulation: hidden injuries, hidden risks .
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psnet.ahrq.gov/node/851158/psn-pdf
June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac
Catheterization
June 28, 2023
Pham TH, Atreja … Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet].
2023. … https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
The … Immediate recognition of iatrogenic injuries during cardiac catheterization enables more timely and … /medical-device-recalls/vascular-solutions-inc-recalls-langston-dual-lumen-catheter-due-risk-separation-during-use