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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - confirming that the tip of the catheter was in the lower half of the superior
vena cava, he closed the wound … The proceduralist must also be on the lookout for injury to surrounding
structures (such as arteries … successful placement and
reducing complications.7-9 Although there is no formal guidance from surgical or medical … In this patient, an injury to the
intercostal artery suggests that the technique utilized to insert … Iatrogenic injury to the intercostal artery: aetiology, diagnosis
and therapeutic intervention.
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psnet.ahrq.gov/issue/decade-preventing-harm
July 10, 2008 - The health system sought to prevent pressure ulcers , adverse drug events , falls with injury , health … January 3, 2017
The cost of serious fall-related injuries at three midwestern hospitals … November 17, 2010
Patient concerns about medical errors in emergency departments. … December 22, 2008
Patients' concerns about medical errors during hospitalization. … November 14, 2011
Temporal trends in rates of patient harm resulting from medical care
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - A recent study in 14 medical units within three academic medical centers found that implementation of … Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized … American Medical Informatics Association; 2012:170.
Dykes PC, Burns Z, Adelman J, et al. … Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized … Fall and injury prevention. In: Hughes RG, ed.
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psnet.ahrq.gov/node/860380/psn-pdf
January 10, 2024 - Validity of 16 AHRQ Patient Safety Indicators to identify
in-hospital complications: a medical record … Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital
complications: a medical record … //psnet.ahrq.gov/issue/validity-16-ahrq-patient-safety-indicators-identify-hospital-complications-
medical-record … The authors attributed low
positive predictive value (PPV) in three of the PSIs (pressure injury, falls … https://psnet.ahrq.gov/issue/validity-16-ahrq-patient-safety-indicators-identify-hospital-complications-medical-record
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psnet.ahrq.gov/issue/comparing-rates-adverse-events-and-medical-errors-inpatient-psychiatric-units-veterans-health
January 30, 2019 - Study
Comparing rates of adverse events and medical errors on inpatient psychiatric … Comparing Rates of Adverse Events and Medical Errors on Inpatient Psychiatric Units at Veterans Health … July 21, 2021
Effectiveness of a graduate medical education program for improving medical … September 19, 2016
Reducing falls and fall-related injuries in mental health: a 1-year … May 5, 2014
Using root cause analysis to reduce falls with injury in the psychiatric
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psnet.ahrq.gov/node/47750/psn-pdf
January 30, 2019 - Association of adverse effects of medical treatment with
mortality in the United States: a secondary … analysis of the
Global Burden of Diseases, Injuries, and Risk Factors
study. … Association of Adverse Effects of Medical Treatment With
Mortality in the United States: A Secondary … Analysis of the Global Burden of Diseases, Injuries, and Risk
Factors Study. … treatment (AEMT) from
the Global Burden of Diseases, Injuries, and Risk Factors 2016 study.
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psnet.ahrq.gov/node/42421/psn-pdf
May 19, 2014 - Do drug interaction alerts between a chemotherapy order-
entry system and an electronic medical record … Do drug interaction alerts between a chemotherapy order-entry
system and an electronic medical record … psnet.ahrq.gov/issue/do-drug-interaction-alerts-between-chemotherapy-order-entry-system-and-
electronic-medical … psnet.ahrq.gov/issue/do-drug-interaction-alerts-between-chemotherapy-order-entry-system-and-electronic-medical … https://psnet.ahrq.gov/issue/computer-alert-system-prevent-injury-adverse-drug-events-development-and-evaluation-community
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psnet.ahrq.gov/issue/safetyleadersorg
August 31, 2011 - Multi-use Website
Safetyleaders.org
Citation Text:
Safetyleaders.org Texas Medical … May 18, 2012
The Institute of Medicine report on medical errors—could it do harm? … Results of the Harvard Medical Practice Study I. … Injury. … March 17, 2011
Indiana Medical Error Reporting System.
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psnet.ahrq.gov/node/45307/psn-pdf
September 07, 2016 - rory-staunton-foundation-sepsis-prevention
https://psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients
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psnet.ahrq.gov/issue/bar-code-technology-medication-administration-medication-errors-and-nurse-satisfaction
July 29, 2020 - Same Author(s)
A randomized trial of a multifactorial strategy to prevent serious fall injuries … October 4, 2011
The road to zero preventable birth injuries. … Related Resources
Impact of interoperability of smart infusion pumps and an electronic medical
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psnet.ahrq.gov/issue/legal-and-policy-interventions-improve-patient-safety
February 17, 2011 - Related Resources From the Same Author(s)
Claims, errors, and compensation payments in medical … February 17, 2011
The medical liability climate and prospects for reform. … April 21, 2015
Beyond negligence: avoidability and medical injury compensation. … January 4, 2012
Administrative compensation for medical injuries: lessons from three
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psnet.ahrq.gov/node/39822/psn-pdf
February 17, 2011 - disclosure-errors
https://psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regarding-disclosure-medical-errors … https://psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients … https://psnet.ahrq.gov/issue/does-full-disclosure-medical-errors-affect-malpractice-liability-jury-still-out … https://psnet.ahrq.gov/issue/disclosure-medical-injury-patients-improbable-risk-management-strategy
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psnet.ahrq.gov/issue/disclosure-adverse-events-pediatrics
April 21, 2021 - McDonnell WM; Altman RL; Bondi SA et al for the Committee on Medical Liability and Risk Management; Council … September 21, 2022
High delayed and missed injury rate after inter-hospital transfer … of severely injured trauma patients. … September 22, 2021
Closing the disclosure gap: medical errors in pediatrics. … November 30, 2016
Disclosure of medical errors involving gametes and embryos.
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psnet.ahrq.gov/issue/simple-surgery-harrowing-complications
November 07, 2012 - Citation
Related Resources From the Same Author(s)
Death of a boy prompts new medical … August 5, 2008
Doctors could learn something about medical handoffs from the Navy. … July 10, 2013
Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy … March 29, 2012
Family of woman who died after a medical error joins hospital's safety … October 19, 2011
Role of intraoperative cholangiography in avoiding bile duct injury.
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psnet.ahrq.gov/issue/interventions-prevent-falls-older-adults-updated-evidence-report-and-systematic-review-us
November 14, 2018 - Falls are a leading cause of injury and death in adults aged 65 years and older, and prevention is a … Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … May 8, 2024
Home Health Agencies Failed To Report Over Half of Falls With Major Injury
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - A recent study in 14 medical units within three academic medical
centers found that implementation of … units within three academic medical centers in Boston and New York City (n=37,231
patients). … Evaluation of a patient-centered fall-prevention tool kit to reduce falls
and injuries: a nonrandomized … Evaluation of a patient-centered fall-prevention tool kit to
reduce falls and injuries: a nonrandomized … Fall and injury prevention. In: Hughes RG, ed.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - need to differentiate between upper motor neuron and lower motor neuron disease
State that spinal cord injuries … neurologic consultation
3
Case: ʺReflexiveʺ Diagnosis
A 54-year-old man with no significant past medical … multiple sclerosis per 1,000 people is 121, 7.1, and 0.9, respectively
Annual incidence of spinal cord injury … Based on the information available, there appears to have been a delay in diagnosis of a spinal cord injury … ) and a lower motor neuron injury (peripheral neuropathy)
14
14
Upper vs.
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psnet.ahrq.gov/node/50370/psn-pdf
January 01, 2020 - Debunking the myth that the majority of medical errors
are attributed to communication. … Debunking the myth that the majority of medical errors are attributed to
communication. … https://psnet.ahrq.gov/issue/debunking-myth-majority-medical-errors-are-attributed-communication
Optimizing … They conclude that medical errors more often result from errors
of commission or omission rather than … ://psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
https://
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psnet.ahrq.gov/issue/disclosure-and-apology-whats-missing-advancing-programs-support-clinicians
December 07, 2016 - Chestnut Hill, MA: Medically Induced Trauma Support Services; 2009. … Chestnut Hill, MA: Medically Induced Trauma Support Services; 2009. … Chestnut Hill, MA: Medically Induced Trauma Support Services; 2009. … February 17, 2017
Ashamed to admit it: owning up to medical error. … May 27, 2011
Framing family conversation after early diagnosis of iatrogenic injury and
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psnet.ahrq.gov/node/44701/psn-pdf
June 07, 2016 - https://psnet.ahrq.gov/issue/problem-preventable-deaths
https://psnet.ahrq.gov/issue/preventing-medical-injury