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psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
September 30, 2010 - Investigators further evaluated cases with available medical records, all of which were among the malpractice … 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 … February 17, 2011
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/issue/extended-work-duration-and-risk-self-reported-percutaneous-injuries-interns
January 07, 2011 - Study
Extended work duration and the risk of self-reported percutaneous injuries … Extended work duration and the risk of self-reported percutaneous injuries in interns. … Extended work duration and the risk of self-reported percutaneous injuries in interns. … Related Resources From the Same Author(s)
Impact of extended-duration shifts on medical … February 24, 2011
Interns' compliance with Accreditation Council for Graduate Medical
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psnet.ahrq.gov/node/44345/psn-pdf
October 05, 2015 - Apologies following an adverse medical event: the
importance of focusing on the consumer's needs. … Apologies following an adverse medical event: The importance of
focusing on the consumer's needs. … https://psnet.ahrq.gov/issue/apologies-following-adverse-medical-event-importance-focusing-consumers- … https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
https://psnet.ahrq.gov … /perspective/removing-insult-injury-disclosing-adverse-events
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psnet.ahrq.gov/primer/falls
October 27, 2021 - More than one-third of in-hospital falls result in injury, including serious injuries such as fractures … and head trauma. … Death or serious injury resulting from a fall while being cared for in a health care facility is considered … Falls that do not result in injury can be serious as well. … Annual Perspective
Measuring and Responding to Deaths From Medical
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psnet.ahrq.gov/web-mm/chemotherapy-extravasation
September 24, 2010 - Consequently, these extravasation injuries often become larger, deeper, and more painful over time. … Therefore, extravasation injuries with these agents generally remain localized, are mildly painful, and … is one too many, particularly since most injuries are preventable.( 2 ) The severity of a vesicant … most likely because the event was detected early), some extravasations may require hospitalization for wound … Retrospective study of the management of chemotherapeutic extravasation injury.
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - However,
cuff pressure values were neither documented in the medical record nor
communicated to the … intubate, ventilatory support for
neuromuscular disease, and as an adjunct to head/neck surgery or trauma … fistulas.6,7
– With the use of the Seldinger technique, complications from esophageal or carotid
injuries … Indications, Complications and Risk Factors of Tracheostomy (4)
• Patient-related risk factors that affect wound … pressure monitoring by manual manometer should be done every 8 to 12 hours and
documented in the medical
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psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
March 23, 2022 - J Trauma Acute Care Surg. 2023. … mortality in emergency general surgery patients using a regional health system integrated electronic medical … March 24, 2021
Zero preventable deaths after traumatic injury: an achievable goal. … June 12, 2019
High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients.
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psnet.ahrq.gov/issue/err-human-disclosure-must-be-taught-simulation-based-assessment-study
August 04, 2021 - August 4, 2021
A randomized trial of a multifactorial strategy to prevent serious fall injuries … September 23, 2020
Information loss in emergency medical services handover of trauma … error using simulation in final-year medical students: linking mindset and experiential learning to … January 3, 2017
Rapid learning of adverse medical event disclosure and apology. … April 8, 2011
Framing family conversation after early diagnosis of iatrogenic injury
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psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
April 26, 2023 - Assessment tools and a medical test checklist are available to aid in prioritization of improvement work … and in-patient/medical team communication. … March 7, 2018
Pressure Injury Prevention in Hospitals Training Program. … October 18, 2017
Preventing Falls With Injury.
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psnet.ahrq.gov/issue/undertriage-elderly-trauma-patients-state-designated-trauma-centers
December 08, 2021 - Study
Undertriage of elderly trauma patients to state-designated trauma centers. … Undertriage of elderly trauma patients to state-designated trauma centers. … Undertriage of elderly trauma patients to state-designated trauma centers. … 2015
Beating the weekend trend: increased mortality in older adult traumatic brain injury … October 11, 2012
Communication errors in dispatch of air medical transport.
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psnet.ahrq.gov/issue/fda-safety-communication-recommendations-reduce-surgical-fires-and-related-patient-injury
October 19, 2022 - FDA Safety Communication: recommendations to reduce surgical fires and related patient injury … Citation Text:
FDA Safety Communication: recommendations to reduce surgical fires and related patient injury … Citation Text:
FDA Safety Communication: recommendations to reduce surgical fires and related patient injury … Copy Citation
Related Resources From the Same Author(s)
Golden State Medical
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psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health
August 02, 2015 - analyses to describe adverse events among veterans aged 65 years and older that resulted in sustained injury … Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical … January 3, 2017
Medical team training and coaching in the veterans health administration … A follow-up study from US Veterans Health Administration medical centers. … August 21, 2013
Using root cause analysis to reduce falls with injury in the psychiatric
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psnet.ahrq.gov/issue/preeminent-hospitals-penalized-over-rates-patients-injuries
January 17, 2018 - Newspaper/Magazine Article
Preeminent hospitals penalized over rates of patients’ injuries … Citation Text:
Preeminent hospitals penalized over rates of patients’ injuries. Rau J. … February 16, 2022
More than 750 hospitals face Medicare crackdown on patient injuries … and Customized Alert Settings Help Improve Management of Sepsis
May 31, 2023
Medical … May 3, 2023
Why hospitals still make serious medical errors—and how they are trying to
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psnet.ahrq.gov/node/47575/psn-pdf
December 19, 2018 - effects-communication-and-resolution-program-hospitals-malpractice-claims-and-costs
https://psnet.ahrq.gov/issue/massachusetts-alliance-communication-and-resolution-following-medical-injury … outcomes-two-massachusetts-hospital-systems-give-reason-optimism-about-communication-and
https://psnet.ahrq.gov/issue/liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program … https://psnet.ahrq.gov/issue/patients-experiences-communication-and-resolution-programs-after-medical-injury
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - Arguably the most severe complication of digital tourniquets, ischemic injuries, have two principal causes … surgeons in the controlled setting of the operating room and may not be generalizable to patients with medical … J Orthop Trauma. 2010 Jun;24(6):387–8.
Smith IM, Austin OMB, Knight SL. … J Trauma. 2006 Dec;61(6):1415–8.
Lahham S, Tu K, Ni M, Tran V, Lotfipour S, Anderson CL, et al. … engagements to enhance interprofessional collaboration and safety behaviors among novice nurses and medical
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psnet.ahrq.gov/issue/who-pays-medical-errors-analysis-adverse-event-costs-medical-liability-system-and-incentives
April 13, 2011 - Study
Classic
Who pays for medical errors? … Who Pays for Medical Errors? … from a past study , investigators determined that hospitals assumed only 22% of costs associated with injuries … reforms or market interventions are also suggested as mechanisms to deal with the externalization of injury … Who Pays for Medical Errors?
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - Delayed or Missed Diagnosis of Cervical Spine Injuries. … The Journal of Trauma: Injury, Infection, and Critical Care. 2006;61(1). doi:10.1097/01.ta.0000196673.58429.2a … The Journal of Trauma: Injury, Infection, and Critical Care . 2006; 61 (1) . … Delayed or Missed Diagnosis of Cervical Spine Injuries. … The Journal of Trauma: Injury, Infection, and Critical Care. 2006;61(1). doi:10.1097/01.ta.0000196673.58429.2a
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psnet.ahrq.gov/issue/system-weaknesses-contributing-causes-accidents-health-care
August 31, 2022 - September 7, 2022
Association of low-dose whole-body computed tomography with missed injury … diagnoses and radiation exposure in patients with blunt multiple trauma. … February 5, 2020
Injuries before and after diagnosis of cancer: nationwide register based … September 27, 2016
Factors associated with adverse events resulting from medical errors … August 15, 2013
Unscheduled returns to the emergency department: an outcome of medical
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psnet.ahrq.gov/node/33878/psn-pdf
April 01, 2019 - For example, in the "medical malpractice" space (what we call
"treatment injury" in New Zealand), an … There will be legal debate about whether the cause was the
preexisting injury or the actual medical … communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters
https://psnet.ahrq.gov/issue/patients-experiences-communication-and-resolution-programs-after-medical-injury … Payments to fix the
medical problem, for example. … excluded
https://psnet.ahrq.gov/issue/patients-experiences-communication-and-resolution-programs-after-medical-injury
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psnet.ahrq.gov/node/47092/psn-pdf
October 13, 2018 - Organizational response to known medical errors: does
peer review protection impede improvement? … Organizational Response to Known Medical Errors: Does Peer Review Protection
Impede Improvement? … https://psnet.ahrq.gov/issue/organizational-response-known-medical-errors-does-peer-review-protection … patient-safety-organization-pso-program
https://psnet.ahrq.gov/issue/whats-past-prologue-organizational-learning-serious-patient-injury … https://psnet.ahrq.gov/issue/whats-past-prologue-organizational-learning-serious-patient-injury
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