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psnet.ahrq.gov/issue/post-traumatic-stress-disorder-amongst-surgical-trainees-unrecognised-risk
August 04, 2021 - Physicians who experience adverse effects after being involved in medical errors have been dubbed … experience psychological consequences as severe as post-traumatic stress disorder following death or serious injury … Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … September 9, 2020
Medical large language models are vulnerable to data-poisoning attacks
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Pain out of proportion to injury severity is a hallmark sign of CS and should have been investigated … from fractures or crush injuries. … Unless there is an associated arterial injury, compartment pressure is rarely elevated sufficiently to … Following implementation of the Accreditation Council for Graduate Medical Education (ACGME) resident … Frequent communication between team members about dynamic clinical conditions reduces the risk of medical
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psnet.ahrq.gov/issue/situation-awareness-errors-anesthesia-and-critical-care-200-cases-critical-incident-reporting
August 03, 2017 - Parents' understanding of medication at discharge and potential harm in children with medical … June 26, 2019
High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients. … February 17, 2021
Delayed medical emergency team calls and associated outcomes. … March 1, 2017
Understanding medical errors and adverse events in ICU patients.
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - thoracic surgery team, in part because there was no active inpatient encounter available in the electronic medical … increased mortality. 18 One systematic review found early diagnosis (defined as the first 24 hours after injury … department (ED) for expedited imaging and close monitoring with subsequent triage to a surgical or medical … the above standard of care, urgency of imaging, and any recent communications with the surgical and medical … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury
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psnet.ahrq.gov/issue/inevitability-physician-burnout-implications-interventions
April 17, 2024 - This commentary explores how medical schools, organizational culture, and working while sick can contribute … , 2024
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury … December 7, 2016
Patient–doctor continuity and diagnosis of cancer: electronic medical … July 31, 2017
Graduate medical education's new focus on resident engagement in quality
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psnet.ahrq.gov/issue/patient-centered-care-improvement-guide
June 10, 2020 - 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.
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psnet.ahrq.gov/issue/improving-safety-information-technology
July 25, 2011 - July 25, 2011
Disclosure of medical injury to patients: an improbable risk management … February 17, 2011
Claims, errors, and compensation payments in medical malpractice litigation … November 11, 2020
Surgical data recording technology: a solution to address medical errors
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psnet.ahrq.gov/issue/adverse-events-0
September 20, 2011 - March 1, 2023
Adverse Events Toolkit: Medical Record Review Methodology. … July 26, 2023
Quality of Care Concerns and the Facility Response Following a Medical … Roudebush VA Medical Center in Indianapolis, Indiana. … December 12, 2023
Home Health Agencies Failed To Report Over Half of Falls With Major Injury … DeBakey VA Medical Center in Houston, Texas.
October 25, 2023
Care Compare.
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psnet.ahrq.gov/issue/image-gently-step-lightly-promoting-radiation-safety-pediatric-interventional-radiology
August 20, 2018 - August 20, 2018
Radiation protection and dose monitoring in medical imaging: a journey … February 26, 2014
6-PACK programme to decrease fall injuries in acute hospitals: cluster … Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury
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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - circumstances combine to place the
elderly nursing home resident at special risk for preventable drug-related injuries … home residents are far likelier than non-institutionalized older persons to have multiple chronic
medical … all of medicine and place older
persons residing in nursing homes at substantial risk of iatrogenic injury … resident-months, of which 40% were considered preventable.(7) Errors associated with
preventable drug-related injuries … than 30 mL/min.(11)
Communication problems are prevalent in the nursing home setting, where many medical
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psnet.ahrq.gov/issue/contemporary-view-medication-related-harm-new-paradigm
July 20, 2012 - July 24, 2019
Error reduction in trauma care: lessons from an anonymized, national, multicenter … The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical … February 10, 2016
Preventing Falls With Injury.
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - Patient death or serious injury associated with intravascular air embolism that occurs while being cared … vessel may be exposed due to underlying disease (e.g., ulcers, mucosal inflammation), scope-induced injury … Safety checklists for emergency response driving and patient transport: experiences from emergency medical … July 7, 2021
Registered nurses' and medical doctors' experiences of patient safety in … April 24, 2024
WebM&M Cases
Uterine Artery Injury
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - wound care and intravenous antibiotics. … Kim, MD Introduction Cerebrospinal fluid (CSF) leaks are a serious complication that can arise from injury … Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury … Occult spinal pseudomeningocele following a trivial injury successfully treated with a lumboperitoneal … January 23, 2019
Classifying errors in preventable and potentially preventable trauma
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psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
September 14, 2022 - May 31, 2023
Non-accidental Injuries in Infants Attending the Emergency Department. … May 31, 2023
Why hospitals still make serious medical errors—and how they are trying … March 15, 2023
Embedded bias: how medical records sow discrimination. … October 5, 2022
When medical error becomes personal, activism becomes painful. … September 16, 2020
Preeminent hospitals penalized over rates of patients’ injuries.
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psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed
March 27, 2005 - Book/Report
Classic
Forgive and Remember: Managing Medical … Citation Text:
Forgive and Remember: Managing Medical Failure. 2nd ed. … In this seminal study, Bosk, a medical sociologist at the University of Pennsylvania, spent a year observing … March 27, 2005
Demanding Medical Excellence. … November 12, 2014
Needlestick injuries among surgeons in training.
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psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-nursing-staff
October 26, 2016 - Medical errors and adverse events can have a devastating psychological impact on the providers involved … September 8, 2021
A randomized trial of a multifactorial strategy to prevent serious fall injuries … practices associated with effective prevention of hospital-acquired pressure ulcers in US academic medical … September 28, 2016
Do nurse and patient injuries share common antecedents?
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psnet.ahrq.gov/issue/crisis-management-during-anaesthesia-development-anaesthetic-crisis-management-manual
June 23, 2015 - November 16, 2022
Changes in medical errors after implementation of a handoff program … Related Resources
WebM&M Cases
Uterine Artery Injury … in Death During Endoscopy
February 28, 2024
Preventing patient positioning injuries
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psnet.ahrq.gov/issue/variations-state-physician-disciplinary-actions-us-medical-licensure-boards
March 12, 2025 - Study
Variations by state in physician disciplinary actions by US medical licensure … Variations by state in physician disciplinary actions by US medical licensure boards. … State medical boards play a critical role in physician oversight . … Variations by state in physician disciplinary actions by US medical licensure boards. … June 11, 2014
A randomized trial of a multifactorial strategy to prevent serious fall injuries
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psnet.ahrq.gov/curated-library/diagnostic-error
April 17, 2025 - The authors analyzed the nature of injuries sustained in a cohort of hospitalized patients in New York … Results of the Harvard Medical Practice Study II. … The authors analyzed the nature of injuries sustained in a cohort of hospitalized patients in New York … Physician reviewers evaluated 1133 injury cases with respect to negligence, errors in management, and … The reviewers found complications from medications were most common, followed by wound infections and
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psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and-patient-safety
January 11, 2017 - between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical … between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical … August 18, 2010
Suicide attempts and completions on medical-surgical and intensive care … September 26, 2017
Suicide attempts and completions on medical-surgical and intensive … August 21, 2013
Using root cause analysis to reduce falls with injury in the psychiatric