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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - Yet, it seems from the case that the patient may have been using his prescribed
opioids for non-medical … overuse and abuse of opioids, including the escalation of the
therapeutic use of opioids, can result in injury … The algorithm involves a 10-step process with diagnosis, determination of medical necessity,
establishment … Laxmaiah Manchikanti, MD
Medical Director, Pain Management Center of Paducah, Paducah, Kentucky
Clinical … other relationship with the manufacturers of any
commercial products discussed in this continuing medical
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - An ADE is defined as "an injury resulting from a medical intervention related to a drug. … productivity losses, or decrements in quality of life.( 9 ) Data from the 2006 National Ambulatory Medical … Electronic medical records with computerized provider order entry systems, when implemented correctly … National Ambulatory Medical Care Survey: 2006 summary. Natl Health Stat Report. 2008:1-39. … Electronic medical record/electronic health record use by office-based physicians: United States, 2008
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - Case Objectives State the rationale for disclosing medical errors. … ICU, he was noted to have fixed and dilated pupils on neurologic exam, a sign of serious neurologic injury … Furthermore, disclosure of medical errors to patients has several benefits. … Communicating with patients about medical errors: a review of the literature. … Disclosing harmful medical errors to patients: tackling three tough cases.
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - Herzig, MD, MPH Instructor in Medicine, Harvard Medical School Division of General Medicine, Beth … Israel Deaconess Medical Center Boston, MA Faculty Disclosure: Dr. … Co-morbidity and utilization of medical services by pain patients receiving opioid medications: data … Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention … Pitfalls
February 1, 2010
WebM&M Cases
Missing Trauma
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psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - Devices that “sustain or support life, are implanted, or present potential high risk of illness or injury … is in itself considered a medical device (Software as a Medical Device [SaMD]). … https://www.fda.gov/medical-devices/resources-you-medical-devices/consumers-medical-devices#How_are_Medical_Devices_Classified … https://www.fda.gov/medical-devices/software-medical-device-samd/what-are-examples-software-medical-device … https://www.fda.gov/medical-devices/medical-device-safety/medsun-medical-product-safety-network .
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 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/web-mm/lost-sign-out-and-documentation
January 31, 2011 - coronary care unit (CCU) with respiratory failure requiring mechanical ventilation and acute kidney injury … Resuscitation status
Medication changes
Primary diagnosis
Route/type of nutrition
Past medical … Rates of medical errors and preventable adverse events among hospitalized children following implementation … survey of clinicians to identify practices and preferences of intensive care unit transfers to general medical
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - assumed that the patient was supposed to be discharged with it in place and did not call anyone from the medical … Developing policies, training, and a safety culture that reduce the risk of injury by making it easier … Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited … sites except for dialysis catheters When aseptic insertion in doubt (i.e., inserted during medical
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - His past medical history was notable for a history of depression, a 40-pack/year history of cigarette … Polevoi, MD Clinical Professor of Emergency Medicine Medical Director, Emergency Department … National Hospital Ambulatory Medical Case Survey: 2005 emergency department summary. … ECG interpretation: sinus tachycardia, with posterolateral injury pattern.
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - 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 realized that the ventilator weaning process was not standardized. … Only one-third of patients who required intubation were considered high risk for extubation failure by medical
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - The authors conclude that EM is a promising approach for medical education given its potential long-term … The authors conclude that EM is a promising approach for medical education given its potential long-term … 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/49809/psn-pdf
October 01, 2017 - event reveals common misconceptions regarding the use of phototherapy, the most
frequently prescribed medical … direct neuroprotective effect.(18) Thus, the immediate and effective (crash-cart) phototherapy in the
medical … Phototherapy and the risk of photo-
oxidative injury in extremely low birth weight infants.
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - 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/web-mm/turn-other-cheek
October 26, 2010 - reported sentinel events , unexpected occurrences involving death or serious physical or psychological injury … Incidence of and risk factors for medical malpractice lawsuits among Mohs surgeons. … prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical
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psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - Landrigan and his colleagues reported the results of their study on sleep deprivation and medical errors … Landrigan, an Assistant Professor of Pediatrics at Harvard Medical School, about his research and his … So we started off
with the goal to look at serious medical errors. … However, if you believe that these kinds of schedules
actually prevent injuries due to medical errors … Effect of reducing interns' work hours on serious medical
errors in intensive care units.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - 2 hours despite adequate fluid resuscitation
Creatinine > 2 mg/dL
Worsening hypoxemia
Acute lung injury … with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
Acute lung injury with PaO2/FiO2
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - I have also served in roles of chief quality officer and chief medical officer in several large systems … and implemented many electronic medical record (EMR) initiatives in those roles. … pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing major injury … healthcare-acquired infections, complications, medication safety, safety of the EMR, patient falls with injury … , and pressure injuries.
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Prior to the widespread implementation of electronic medical records (EMRs), organizations typically … and implemented many electronic medical record (EMR) initiatives in those roles. … pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing major injury … healthcare-acquired infections, complications, medication safety, safety of the EMR, patient falls with injury … , and pressure injuries.
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - reported sentinel events,
unexpected occurrences involving death or serious physical or psychological injury … Incidence of and risk factors for medical
malpractice lawsuits among Mohs surgeons.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - Abuhamad, MD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School
Editor, AHRQ WebM … (2)
The infant subsequently had multiple seizures typical of hypoxic-ischemic encephalopathy (brain injury