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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - safety pin could be aspirated, or a non-deformable endotracheal tube connector might cause a pressure injury … patient, including morbidity from the RFO, loss of patient trust, and additional costs related to the medical … Washington School of Medicine Chair, Coordinated Quality Improvement Program University of Washington Medical
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - //psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Instructor in Medicine, Harvard Medical … School
Division of General Medicine, Beth Israel Deaconess Medical Center
Boston, MA
Faculty Disclosure … other relationship with the manufacturers of any commercial products
discussed in this continuing medical … 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
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - Another problem might be that they're not owned medical staff, if you will. … So incorporating that into medical school and even residency would help. … these missteps happens with stunning frequency in office practice, and each creates a potential for injury … A preliminary taxonomy of medical errors in family practice. … The Unity of Mistakes: A Phenomenological Analysis of Medical Work.
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psnet.ahrq.gov/node/49748/psn-pdf
December 01, 2015 - This is because the risk of developing
acute kidney injury and/or hepatorenal syndrome is highest in
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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - These technologies are now commonly applied in virtually every medical specialty to educate, monitor, … center to manage treatment of children with serious illness or injury in eight rural EDs in California … The exponential growth of mobile medical applications raises new safety concerns. … Skin scan: a demonstration of the need for FDA regulation of medical apps on iPhone. … November 12, 2014
An analysis of medical malpractice claims against medical oncologists
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psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - Purchasing provides an opportunity to shape the safety and usability of medical technology. … Arlington, VA: Association for the Advancement of Medical Instrumentation; 2010. … Injuries are caused by a lack of differentiation between the use of infusion devices in hospitals and … Infusion pump: A medical device used to deliver fluids into a patient's body in a controlled manner. … April 19, 2017
Changes in weekend and weekday care quality of emergency medical admissions
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - demonstrate an average or below average R-AHMR, given that most quality problems, while associated with injury … is an emeritus professor at Imperial College School of Medicine and a past president of the British Medical … We as a medical profession had an obligation to make that information available for these parents. … We had in a very large room 2000 medical notes from Bristol. … RW : There's been debate in the medical literature about using the HSMR as a quality measure, and some
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - These criteria are somewhat analogous to what has been developed for medical admissions but modified … Medical devices are a valuable adjunct for monitoring patient status since physiological triggers are … Validation of a modified Early Warning Score in medical admissions. … Medical device alarm safety in hospitals. … October 30, 2024
WebM&M Cases
Uterine Artery Injury during
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection … errors have the potential to be serious and may result in adverse drug events (ADE), which are patient injuries … teach-back, it is important to speak slowly, make eye contact, use relaxed body language, avoid complex medical … Patients' memory for medical information. … Reducing Medical Admissions and Presentations Into Hospital through Optimising Medicines (REMAIN HOME
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - He served as the American Medical Association's senior vice president of professional standards, and … In some ways, it simply expands how care is delivered today, making it possible for traditional medical … center to manage treatment of children with serious illness or injury in eight rural EDs in California … The exponential growth of mobile medical applications raises new safety concerns. … Skin scan: a demonstration of the need for FDA regulation of medical apps on iPhone.
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psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
December 23, 2020 - The Accreditation Council for Continuing Medical Education (ACCME) defines a commercial interest as “ … For example, resuscitating a patient who is DNR (“do not resuscitate”) can lead to injury to the patient … Key role of social work in effective communication and conflict resolution process: Medical Orders for … Life-Sustaining Treatment (MOLST) Program in New York and shared medical decision making at the end … Role of a medical social worker in improving quality of life for patients with advanced cancer with a
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - decisions are based on some kind of pathology and/or laboratory result. 1 Medical testing consists … A study by the University of Minnesota Medical Center (UMMC) laboratory found their facility could not … infections, such as sepsis, exponentially increases the odds of death. 13 Costs associated with iatrogenic injuries … Medical testing error occurs most frequently during the pre-analytic phase. … A review of medical errors in laboratory diagnostics and where we are today.
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - injuries.( 16 )
Although electronic mechanisms for written signout can facilitate the standardization … Center, and Graduate Medical Education (GME) leadership.
3. & 4. … Ideally, these structures will be integrated into an electronic medical record. … London, England: British Medical Association; August 2004. … Effect of reducing interns' work hours on serious medical errors in intensive care units.
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - ED and surgery) may contribute to medical error. … Patients with dangerous medical conditions and traumatic injuries may
present with normal or near-normal … and trauma patients.20
Several strategies exist to help crowded EDs minimize harm and reduce delays … utilizing “aides to replicate clinical scenarios.”25 A recent focused
review of simulation used for acute trauma … Multidisciplinary Simulation-Based Team Training for Trauma
Resuscitation: A Scoping Review.
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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - Cellular connected medical devices are always
available. … We often try to use emergency medical technicians or paramedics. … Historically, these are acute problems that arise where there is
illness or injury. … Medical care can be challenging in that
situation. … When we gave out the
medical devices, we could call patients.
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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - Even in the absence of a history suggestive of esophageal perforation
(instrumentation, injury, vomiting … Utter, MD MSc
Professor of Surgery
Division of Trauma, Acute Care Surgery, and Surgical Critical
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - 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 … For example, resuscitating a patient who is DNR (“do not resuscitate”) can
lead to injury to the patient … Life-Sustaining Treatment (MOLST) Program in New York
and shared medical decision making at the end … Role of a medical social worker in improving quality of life
for patients with advanced cancer with
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psnet.ahrq.gov/classics
August 01, 2023 - Factors Engineering
(92)
Checklists
(32)
Forcing Functions
(5)
Medical … Alarm Design
(3)
Medical Device Design
(5)
Legal and Policy Approaches … 4)
Inpatient suicide
(1)
Interruptions and distractions
(5)
Medical … This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing … clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries
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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - and the design and location of hazards like
furniture—can contribute to patient falls and associated injuries
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - be-picky-about-your-piccs-fragmented-care-and-poor-communication-
discharge-leads-picc
The Case
A 20-year-old woman with a past medical … of a triad of factors (Virchow’s triad)–consisting of hypercoagulability, stasis, and endothelial
injury–which … coordination of care activities, such as ensuring home health
services, making follow-up appointments with medical … providers, and obtaining durable medical supplies
and medications at discharge, are critical to patient … central line and
under what circumstances they should contact a healthcare provider or seek immediate medical