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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - harmed by having the incorrect catheter placed, but the error
was eventually discovered and further injury … power hierarchy—individuals of lesser status in the medical hierarchy may be reluctant
to check, let … Craig Blackmore, MD, MPH Director, Center for Health Care Improvement Science Virginia Mason
Medical … other relationship with the manufacturers of any commercial
products discussed in this continuing medical … does not
include information regarding investigational or off-label use of pharmaceutical products or medical
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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Upon arrival at the hospital, she was diagnosed with severe dehydration, hypotension, and acute kidney injury … Some acceptable patient identifiers include patient name, assigned identification number (such as medical … CDSS software improves medication safety by augmenting clinicians’ ability to make safe and effective medical … Using CDSS software aids clinicians in medical decision-making and reduces medication errors by providing … mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand … Past medical history was notable for stroke with residual left-sided hemiparesis, hypertension, coronary … signed and faxed to the other hospital to obtain records of the recent ED visit for the ankle and foot injury … or other relationship with the manufacturers of any commercial products discussed in this continuing medical … does not include information regarding investigational or off-label use of pharmaceutical products or medical
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - Succinylcholine is contraindicated in patients with stroke, spinal cord injury, burns, or myotonic dystrophy … inadequate resources such as the broken drug refrigerator otherwise could have led to irreversible injury … Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers
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psnet.ahrq.gov/node/49553/psn-pdf
January 01, 2008 - These include:
A patient with multiple underlying medical problems that predispose to infection;
Isolation … To reduce the risk of needlestick injury associated with changing needles, the
standard culture method … But
Corynebacterium can cause clinically significant infections in the presence of medical devices such … Apparently, the PCP was not made aware of this event (a communication error), and
no medical intervention … Coagulase-negative staphylococci: pathogens associated with medical progress.
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psnet.ahrq.gov/node/50613/psn-pdf
October 30, 2019 - , MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive
Biology at Harvard Medical … The
odds of experiencing a hemorrhage, sepsis, or organ injury are about three times higher with cesarean … If you're a
neurosurgeon or a trauma surgeon, and you go back and operate on the place that you operated … How much of it is medical malpractice? … Medical malpractice doesn't explain it, nor does reimbursement.
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - should be able to:
• Discuss the importance of miscommunication in radiology as a
contributor to medical … complaining of intermittent left shoulder pain
for several years was diagnosed with a rotator cuff injury
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - ref1
https://psnet.ahrq.gov//#ref3
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with injury … quality of care.(7) And what do we do with the patient rendered "palliative" by some rare but
egregious medical
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psnet.ahrq.gov/web-mm/saved-ecmo
May 05, 2017 - Related Resources
WebM&M Cases
Uterine Artery Injury … See More About The Topic
Labor and Delivery
Obstetrics
Surgery
Obstetrical Nursing
Medical
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - from the patient, his partner, or the medical record. … additional history-taking may have revealed the patient’s recent history of falls with repeated closed head injuries … “Has this patient suffered recent head trauma or is this patient at increased risk of head trauma?”) … Forcing functions are common in non-medical settings. … Various medical forcing functions are already in use.
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - The Accreditation Council for Continuing Medical Education (ACCME) defines an ineligible company as “ … Awareness is also more common during emergency operations for acute trauma. … Trauma anesthesia care has been improving over time; a recent study found that awareness in trauma patients … Awareness during anesthesia for trauma: has anything changed? … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - patient on the same unit who also happened to have severe cognitive impairment from a traumatic brain injury … Key lessons to consider include: Review your HIPAA and state medical privacy law policies to ensure … From 1993 to 1996, one of us (JH) was a resident in Emergency Medicine at Harbor-UCLA Medical Center. … , Harvard Medical School Deven McGraw, JD, MPH, LLM Partner, Manatt, Phelps & Phillips LLP Faculty … Privacy and Security Solutions for Interoperable Health Information Exchange: Report on State Medical
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical … The Accreditation Council for Continuing Medical Education (ACCME) defines a commercial
interest as … She was admitted by a second-year medical resident who ordered the appropriate
https://psnet.ahrq.gov … In the morning, the admitting resident presented the case to the daytime medical team, including
the … an unwanted resuscitation with extreme consequences, including CPR-
related fractures, anoxic brain injury
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - Case & Commentary—Part 1: A frail 80-year-old man with a past medical history of dementia, falls, and … The medical team correctly continued the patient's warfarin on admission; patients in whom warfarin is … Although the patient's INR on discharge was therapeutic, the medical team should have anticipated that … The medical team probably should have also either spoken directly with the primary care doctor at the … Beyond the Hospital: the New Frontier of Patient Safety
August 22, 2014
Injuries
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - Evaluation of an emergency radiology quality assurance program at a level I trauma center: abdominal … Head trauma: CT scan interpretation by radiology residents versus staff radiologists. … sonography by radiology residents versus final interpretations by body imaging radiologists at a level 1 trauma … Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients … May 1, 2011
Delayed or missed diagnosis of cervical spine injuries.
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - In addition, the electronic medical record (EMR) features an order set to assist clinicians in ordering … Kanter, Michael.H.Kanter@kp.org , Southern California Permanente Medical Group and Kaiser Permanente … Medicine, Pasadena, California
Ali Ghobadi, Ali.X.Ghobadi@kp.org , Southern California Permanente Medical … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury … Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - arrival at the hospital, she was diagnosed
with severe dehydration, hypotension, and acute kidney injury … Some acceptable
patient identifiers include patient name, assigned identification number (such as medical … CDSS software improves medication safety by augmenting clinicians’ ability to make safe and
effective medical … Using CDSS software aids clinicians in medical decision-making and reduces medication errors by
providing
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psnet.ahrq.gov/node/843150/psn-pdf
December 05, 2022 - People may go to a provider
because they have an injury or concern, and providers can only focus on … There is also that trauma of accessing care and feeling that bias and stigma, which can prevent patients … That trauma hinders the ability to sometimes see when people, like clinicians, are asking for the right … all have people we love, we all are beings trying to get through this world with the
least amount of trauma … Emergency Medical Treatment & Labor Act (EMTALA). Center for Medicare and Medicaid Services.
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - Relevant Financial Relationships: As a provider accredited by the Accreditation Council
for Continuing Medical … The Accreditation Council for Continuing Medical
Education (ACCME) defines a commercial interest as … Laboratory tests were notable for acute kidney injury,
metabolic acidosis, hypomagnesemia, hypophosphatemia … Capacity is defined as a person’s ability to make an informed decision about medical treatments
and … Evaluating medical decision-making capacity in practice. Am Fam
Physician. 2018;98(1):40-49.
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psnet.ahrq.gov/node/33721/psn-pdf
November 01, 2011 - Veterans Health Administration (VHA) National Center for Patient Safety (NCPS) implemented the
national Medical … Using existing simulation centers, especially at larger, university-affiliated medical centers,
has … Association between implementation of a medical team training
program and surgical mortality. … Medical team training and coaching in the Veterans Health Administration;
assessment and impact on the … Reducing falls and fall-related injuries in
the VA system. J Healthc Saf Q. 2003;1:25-33.
8.