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psnet.ahrq.gov/node/38116/psn-pdf
February 18, 2011 - prior research documents a link between increased fatigue and self-reported
errors and percutaneous injuries … in cognitive specialties (including internal medicine, pediatrics, and
psychiatry) at an academic medical … issue/factors-associated-intern-fatigue
https://psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures … https://psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures … https://psnet.ahrq.gov/issue/extended-work-duration-and-risk-self-reported-percutaneous-injuries-interns
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - The intern came from a hospital system (as a medical student) that relied entirely on paper orders. … Fresh from medical school graduation and a crash course politely referred to as "resident orientation … failed to demonstrate increases in adverse outcomes in morbidity or mortality in areas that include trauma … Braddock III, MD, MPH Associate Professor of Medicine Associate Dean, Office of Medical Education … , 2017
The clinical transformation of Ascension Health: eliminating all preventable injuries
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psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - The 2009 Standards of Medical Care in Diabetes published by the
American Diabetes Association (ADA) … other relationship with the manufacturers of any commercial products discussed in
this continuing medical … Standards of medical care in diabetes—2009. Diabetes Care.
2009;32(suppl 1):S13-S61. … )
88.0 71.4 44.7
No. of emergency department (ED) visits attributed to nonfatal
sexual assault injuries … 27,469 28,388 19,777 29,553
Rate per 100,000 population of ED visits for nonfatal sexual
assault injuries
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - His past medical history included hypertension treated with
lisinopril, diabetes treated with metformin … The patient’s laboratory results were notable for
acute kidney injury and metabolic acidosis, with an … improvement project in Singapore between February 2012 and June 2013, 320 CVCs were
inserted in the medical … intensive care unit and a medical intermediate care unit using a customized line kit
that had drape … Professor
Department of Internal Medicine, Division of Nephrology
University of California, Davis Medical
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - event reveals common misconceptions regarding the use of phototherapy, the most frequently prescribed medical … Phototherapy and the risk of photo-oxidative injury in extremely low birth weight infants. … WebM&M Cases
The Wet Read
March 1, 2006
Medical … Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical … , 2023
A multisite study of interprofessional teamwork and collaboration on general medical
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - This study, conducted with medical students and residents at two academic medical centers, examined the … This study, conducted with medical students and residents at two academic medical centers, examined the … Safety Research and Practice at Brigham and Women’s Hospital and a Professor of Medicine at Harvard Medical … continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury
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psnet.ahrq.gov/node/41940/psn-pdf
April 21, 2015 - strategies-broad
Some hospital systems have employed a disclosure, apology, and offer strategy for medical … /disclosure-errors
https://psnet.ahrq.gov/issue/liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program … https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
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psnet.ahrq.gov/node/49396/psn-pdf
April 01, 2003 - Difficult-to-read patient records and
prescriptions waste time and produce errors,(4-6) causing serious injury … Since mix-ups between Zyprexa and Zyrtec are potentially serious, nurses, medical staff (including
psychiatrists … American Medical News. November
22/29, 1999. [ go to related site ]
8.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
May 01, 2014 - out of the patient's admission medication list
This omission resulted in unnecessary and preventable injury … day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical … Medical
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - ’s slow or ineffective response to clinical deterioration resulting from an underlying illness or a medical … recognition of and deterioration following breakdown of an anastomosis , patient fall risk and staff injury … Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Case
A 47-year-old man with paraplegia (secondary to a gunshot wound) and a history of polysubstance … Unfortunately, his cardiac arrest led to an anoxic brain injury, and he remained in a vegetative state … record system is no substitute for good
medical practice. … Neither the commentary nor
continuing medical education activity includes information regarding any … commercial products or
investigational or off-label use of pharmaceutical products or medical devices
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - The trauma team was called to assist and the patient was given additional sedation and opioid analgesia … The trauma surgeon then manipulated both TMJs and was finally able to unloose the locked jaw. … diagnosis and a physician experienced in reducing the TMJ should be consulted to minimize the risk of injury … The reasons for this type of event should be clearly documented in the patient’s medical record. … Clearly highlight the problem in the medical record
A reintubation or unexpected ICU admission due
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psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - While other imaging techniques also use radiation, CT is estimated to account for half of all medical … Variability in radiation dose also plays a role in the increasing radiation exposure attributable to medical … this number is likely an underestimate, since there is currently no mandatory reporting standard for injuries … The Joint Commission also has promoted a public awareness campaign on medical imaging safety. … October 31, 2014
The impact of computerized provider order entry systems on medical-imaging services
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - laboratory
data was notable for an elevated white blood cell (WBC) count of 23,000/mm3, acute kidney injury … In reviewing her medical record, the admitting team noted she had been admitted 3 times in the
last … William Martinez, MD, MS
Assistant Professor of Medicine
Vanderbilt University Medical Center
Gerald … Medical
professionalism in the new millennium: a physician charter. … Emergency physicians and disclosure of medical
errors. Ann Emerg Med. 2006;48:523-531.
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psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - lead to a substantial number of false-positive atrial
fibrillation diagnoses and prompt unnecessary medical … Our view is that such a machine will not fit well into existing definitions of a medical
device, but … Medical diagnostic decision support systems—past, present, and future: a threaded
bibliography and brief … Calibration drift in regression and machine
learning models for acute kidney injury.
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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - If there is no cuff leak, it suggests that
laryngeal edema or another type of laryngeal injury has reduced … The ICU medical director reviewed the case and discovered that the physician had forgotten to place an … The medical director also
https://psnet.ahrq.gov/web-mm/premature-extubation
realized that the ventilator … one-third of patients
who required intubation were considered high risk for extubation failure by medical
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - consulting nephrologist felt that amphotericin toxicity was the most
likely cause of the acute kidney injury … and was surprised to find that the
patient had no positive blood cultures reported in the electronic medical … more physicians, nurses, and pharmacists.(10) Team members are aware of
key aspects of each patient's medical … Filice, MD Chief, Infectious Disease Section, Veterans Affairs Medical Professor of Medicine
University
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psnet.ahrq.gov/issue/iatrogenic-disease
March 19, 2008 - January 23, 2019
Medical Errors and Safety Systems. … June 26, 2013
The road to zero preventable birth injuries. … September 24, 2010
Medical Errors and Safety Systems. … March 3, 2010
National safety effort targets perinatal injuries.
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - grams intravenously twice daily was initiated, and the patient was transferred to a large academic medical … The Commentary
Acute kidney injury (AKI) is a common condition associated with up to 7% of all hospital … To facilitate early detection of AKI and allow prompt intervention, the Acute Kidney Injury Network has … Biomarkers of acute kidney injury. Annu Rev Pharmacol Toxicol. 2008;48:463-493. … Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury.
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psnet.ahrq.gov/node/39644/psn-pdf
June 30, 2010 - per week were strongly correlated with an increase in self-reported errors,
particularly needlestick injuries … working-hours-hospital-staff-nurses-and-patient-safety
https://psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures … https://psnet.ahrq.gov/issue/extended-work-duration-and-risk-self-reported-percutaneous-injuries-interns