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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - no injury. … injury to that person and their psyche. … We published our results in the Journal of the American Medical Association (JAMA). … In hospitals, falls with injuries can lead to other adverse outcomes including pressure injuries or … Make STEADI part of your medical practice. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/visual-illusions-radiology-untrue-perceptions-medical-images-and-their-implications
July 06, 2022 - Commentary
Visual illusions in radiology: untrue perceptions in medical images and … Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnostic … May 13, 2020
Association of low-dose whole-body computed tomography with missed injury … diagnoses and radiation exposure in patients with blunt multiple trauma. … Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury
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psnet.ahrq.gov/issue/uncovering-system-errors-using-rapid-response-team-cross-coverage-caught-crossfire
April 24, 2018 - The Journal of Trauma: Injury, Infection, and Critical Care. 2009;67(1). doi:10.1097/ta.0b013e31819ea514 … The Journal of Trauma: Injury, Infection, and Critical Care . 2009; 67 (1) . … The Journal of Trauma: Injury, Infection, and Critical Care. 2009;67(1). doi:10.1097/ta.0b013e31819ea514 … Settings Help Improve Management of Sepsis
May 31, 2023
Care transition of trauma … Medication Reconciliation Pitfalls
February 1, 2010
The use of medical
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psnet.ahrq.gov/taxonomy/term/3437
April 02, 2025 - Adverse Event
Any injury caused by medical care. … Examples: pneumothorax from central venous catheter placement anaphylaxis to penicillin postoperative wound … Similarly, postoperative wound infections count as adverse events even if the operation proceeded with
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psnet.ahrq.gov/issue/advising-patients-about-patient-safety-current-initiatives-risk-shifting-responsibility
May 20, 2015 - injury to patients: an improbable risk management strategy. … February 3, 2011
Medical monitoring for pharmaceutical injuries: tort law for the public's … April 21, 2015
Who pays for medical errors? … February 4, 2015
Beyond negligence: avoidability and medical injury compensation. … January 4, 2012
Patient safety and medical malpractice: a case study.
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - The affected tissue demonstrates markedly compromised integrity and impaired wound healing, which dramatically … , as well as patient factors such as medical comorbidities, fitness, and health literacy and engagement … For patients with complex medical conditions and ongoing surgical needs, joint ownership of the care … In fact, a common theme of successful surgical and medical co-management models is the involvement of … Nationwide comparison of the medical complexity of patients by surgical specialty.
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psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims
August 04, 2021 - Study
Communication failures contributing to patient injury in anaesthesia malpractice … Communication failures contributing to patient injury in anaesthesia malpractice claims. … Communication failures contributing to patient injury in anaesthesia malpractice claims. … February 9, 2022
Injury and liability associated with monitored anesthesia care: a closed … February 8, 2023
Medical malpractice lawsuits involving trainees in obstetrics and gynecology
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psnet.ahrq.gov/issue/prevalence-and-nature-adverse-medical-device-events-hospitalized-children
October 05, 2011 - Prevalence and nature of adverse medical device events in hospitalized children. … Such injuries have been studied in adult inpatients , but this study represents the first population-based … estimate of harm caused by medical devices in hospitalized children. … the investigators found that approximately 1 in 300 pediatric inpatients experienced a device-related injury … Prior research using voluntarily reported data has shown that device injuries are among the most common
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psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities
December 23, 2016 - Sentinel Event Alerts
Preventing falls and fall-related injuries in health care facilities … Citation Text:
Preventing falls and fall-related injuries in health care facilities. … Falls in the hospital are common, particularly among elderly patients , and falls resulting in serious injury … Cite
Citation
Citation Text:
Preventing falls and fall-related injuries … November 24, 2021
Medical device alarm safety in hospitals.
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psnet.ahrq.gov/issue/optimizing-patient-handoff-between-ems-and-emergency-department
April 24, 2018 - Optimizing the patient handoff between emergency medical services and the emergency department. … Optimizing the patient handoff between emergency medical services and the emergency department. … April 12, 2019
Addressing prehospital patient safety using the science of injury prevention … August 9, 2023
High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients.
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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/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - What we found in our recent study was that one in four patients suffers an injury during a hospitalization … will develop a dangerous pressure injury. … But if you are seeing a patient with an ankle injury, it should be underscored that there is a rule so … AI to figure out how severe the injury has been. … In the Harvard Medical Practice Study , nurses and medical records analysts screened 31,429 records
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psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
March 03, 2011 - Classic
Patterns of communication breakdowns resulting in injury … Patterns of communication breakdowns resulting in injury to surgical patients. … Patterns of communication breakdowns resulting in injury to surgical patients. … Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury … 21, 2014
Surgical case listing accuracy: failure analysis at a high-volume academic medical
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psnet.ahrq.gov/issue/preventing-patient-positioning-injuries-nonoperating-room-setting
November 21, 2012 - Preventing patient positioning injuries in the nonoperating room setting. … Hospital-acquired pressure injuries are considered a never event . … Preventing patient positioning injuries in the nonoperating room setting. … August 12, 2020
Errors in medicine: punishment versus learning medical adverse events … March 24, 2021
Provider bias in prescribing opioid analgesics: a study of electronic medical
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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/issue/analysis-surgical-errors-closed-malpractice-claims-4-liability-insurers
February 17, 2011 - The cases resulted in significant harm: 23% of the patients died, and 65% suffered disabling injuries … Related Resources From the Same Author(s)
Claims, errors, and compensation payments in medical … October 26, 2010
Patterns of communication breakdowns resulting in injury to surgical … August 26, 2011
Who pays for medical errors? … July 10, 2008
Disclosure of medical injury to patients: an improbable risk management
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - defined an adverse event as "an injury that was caused by medical management (rather than the underlying … The Institute for Healthcare Improvement uses a similar definition: unintended physical injury resulting … These adverse events were the focus of both the Medical Insurance Feasibility Study and the Harvard Medical … Ameliorable adverse events are those that are not preventable, but the severity of the injury "could … Ten days later, the patient presents to the emergency department with acute kidney injury and critically
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - defined an adverse event as "an injury that was
caused by medical management (rather than the underlying … The Institute for Healthcare
Improvement uses a similar definition: unintended physical injury resulting … Medical
Practice Study. … Ameliorable adverse events are those that are not preventable, but the
severity of the injury "could … A near miss is defined as "an event or situation that did not produce patient
injury, but only because
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psnet.ahrq.gov/issue/social-capital-and-knowledge-sharing-effects-patient-safety
September 15, 2011 - Related Resources From the Same Author(s)
System approach to prevent common bile duct injury … September 15, 2011
Surgeon commitment to trauma care decreases missed injuries. … mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical … STOPP-J criteria and risks of hospitalization and mortality in elderly patients receiving home-based medical … January 9, 2011
The culture of a trauma team in relation to human factors.
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psnet.ahrq.gov/issue/intraoperative-deaths-who-why-and-can-we-prevent-them
November 04, 2020 - This study analyzed five years of data on IODs from a large academic medical center. … The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related … emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or … vascular injuries. … the Same Author(s)
Cognitive bias impact on management of postoperative complications, medical