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psnet.ahrq.gov/node/44591/psn-pdf
March 15, 2016 - lacerations-and-embedded-needles-caused-epinephrine-autoinjector-use-
children
This study describes injuries … The injuries described in this case
series underscore the need to improve medical device design and … lacerations-and-embedded-needles-caused-epinephrine-autoinjector-use-children
https://psnet.ahrq.gov/issue/emergency-department-visits-medical-device-associated-adverse-events-among-children … https://psnet.ahrq.gov/perspective/safety-medical-devices
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psnet.ahrq.gov/issue/opioid-prescribing-patterns-and-complications-dermatology-medicare-population
May 25, 2022 - July 12, 2023
Injuries before and after diagnosis of cancer: nationwide register based … October 19, 2016
Framing family conversation after early diagnosis of iatrogenic injury … April 27, 2022
State medical board regulation of compounding in physician offices. … March 18, 2020
Characteristics of medical liability claims against dermatologists from … 2012
Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical
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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - The day I arrived at Alcoa, even though they were already in the top 20% or so of avoiding injuries to … their
workforce, I announced we should be an injury-free workplace. … And over the 13 years I was there we got
close to achieving zero injuries. … Their OSHA recordable number says 7 people out of every 100 of their staff have an injury every
year … safety data system that people use as a screen saver, and you can see if your friend on ward C had
an injury
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psnet.ahrq.gov/issue/hospital-autopsy-endangered-or-extinct
November 21, 2021 - November 16, 2022
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 … November 3, 2015
Medical costs of Alzheimer's disease misdiagnosis among US Medicare … August 26, 2015
Classifying errors in preventable and potentially preventable trauma … April 9, 2013
The impact of clinically undiagnosed injuries on survival estimates.
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - Catheter insertion can result in arterial injury and related hematomas, hemopneumothorax, and dangerous … In a medical care setting, a critical care handover formal checklist can be completed rapidly when necessary … Importantly, experience teaches that it takes only one patient save in which an impending injury was … January 7, 2015
Standards for patient monitoring during general anesthesia at Harvard Medical … Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical
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psnet.ahrq.gov/node/34704/psn-pdf
December 24, 2008 - negligent-care-and-malpractice-claiming-behavior-utah-and-colorado
The authors analyzed the relationship between negligent medical … error and the filing of medical liability
claims in a review of 15,000 hospital discharges in Utah … They reviewed each case for the
presence of iatrogenic injury resulting from negligence and matched … the set of cases against the medical
malpractice claims filed in the two states.
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psnet.ahrq.gov/node/841482/psn-pdf
December 14, 2022 - retrospective review of patients
undergoing surgery at one hospital over a one-year period concluded that medical … psnet.ahrq.gov/issue/patterns-technical-error-among-surgical-malpractice-claims-analysis-strategies-prevent-injury
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psnet.ahrq.gov/node/35880/psn-pdf
April 12, 2008 - executives need to be more committed to addressing the underlying
cause of the liability crisis—patient injury … during the course of medical care.
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psnet.ahrq.gov/issue/drill-down-root-cause-analysis
June 15, 2016 - Related Resources From the Same Author(s)
A case of transfusion error in a trauma … May 25, 2022
Root cause analysis for hospital-acquired pressure injury. … March 4, 2015
Disclosing harmful medical errors to patients: a time for professional … March 3, 2011
Making patient safety the centerpiece of medical liability reform. … August 5, 2010
Doctors, lawyers make deal on medical-malpractice bill.
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psnet.ahrq.gov/web-mm/recurrent-appendicitis
January 15, 2020 - The surgeon had recently joined the medical staff after completing a general surgery residency and then … The Commentary This case provides an opportunity to review two important issues in surgery: (i) medical … in the elderly compared to approximately 20% in the general population).( 2,3,6 ) The most common medical … If a laparoscopic approach is used, there is the additional risk of injury during trocar (the port used … Greenberg, MD, MPH Assistant Professor of Surgery, Harvard Medical School Director, Center for
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - State that spinal cord injuries are common and often misdiagnosed. … The Case
A 54-year-old man with no significant past medical history presented to a new primary care … large prevalence of
neurologic disease coupled with an increasing emphasis on primary care-focused medical … overall incidence ranging from 10%–20%, resulting in
40,000–80,000 deaths per year and countless more injuries … and a lower motor neuron injury from peripheral neuropathy (Table 1).
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psnet.ahrq.gov/node/42924/psn-pdf
April 24, 2014 - Role-modeling and medical error disclosure: a national
survey of trainees. … Role-modeling and medical error disclosure: a national survey of
trainees. … https://psnet.ahrq.gov/issue/role-modeling-and-medical-error-disclosure-national-survey-trainees
Although … Since few training programs include formal curricula in error
disclosure, most residents and medical … https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
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psnet.ahrq.gov/issue/risks-complications-attending-physicians-after-performing-nighttime-procedures
February 14, 2018 - sleep-deprived residents are more prone to committing errors and inadvertently sustaining needlestick injuries … September 9, 2015
Changes in medical errors after implementation of a handoff program … February 17, 2011
Effect of reducing interns' work hours on serious medical errors in … September 21, 2022
Communication failures contributing to patient injury in anaesthesia … A follow-up study from US Veterans Health Administration medical centers.
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psnet.ahrq.gov/issue/prevalence-types-and-sources-bullying-reported-us-general-surgery-residents-2019
May 06, 2020 - Related Resources From the Same Author(s)
Association of surgical resident wellness with medical … March 2, 2011
Framing family conversation after early diagnosis of iatrogenic injury … February 25, 2009
Laparoscopic bile duct injury: understanding the psychology and heuristics
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psnet.ahrq.gov/node/865658/psn-pdf
April 24, 2024 - Since they are
considered non-medical facilities, they are not required to have nurses, certified nursing … this case a Hoyer lift, that would not only enhance safe
patient care but also help to prevent staff injury … In California, administrators report using the LIC 624 Unusual Incident/Injury Report form,8 which
can … two-person assistance by themselves, the facility will
more likely be cited for deficiency especially if an injury … Lic 624 – Unusual
Incident/Injury Report. Accessed December 21, 2023.
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psnet.ahrq.gov/issue/improving-patient-safety-hospitals-contributions-high-reliability-theory-and-normal-accident
October 13, 2010 - Same Author(s)
What’s past is prologue: organizational learning from a serious patient injury … From research to practice: factors affecting implementation of prospective targeted injury-detection … November 3, 2015
Six year audit of cardiac arrests and medical emergency team calls in
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psnet.ahrq.gov/issue/prevention-retained-surgical-sponges-decision-analytic-model-predicting-relative-cost
January 04, 2010 - Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury … March 3, 2011
Patterns of communication breakdowns resulting in injury to surgical patients … 2, 2011
Surgical case listing accuracy: failure analysis at a high-volume academic medical
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psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - grams intravenously twice daily was initiated, and the patient
was transferred to a large academic medical … The Commentary
Acute kidney injury (AKI) is a common condition associated with up to 7% of all hospital … To facilitate early detection of AKI and allow
prompt intervention, the Acute Kidney Injury Network … Biomarkers of acute kidney injury. Annu Rev Pharmacol
Toxicol. 2008;48:463-493. [go to PubMed]
2. … Acute Kidney Injury Network: report of an initiative to improve
outcomes in acute kidney injury.
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psnet.ahrq.gov/node/36530/psn-pdf
January 07, 2011 - Impact of extended-duration shifts on medical errors,
adverse events, and attentional failures. … Impact of extended-duration shifts on medical errors, adverse events,
and attentional failures. … physicians and
patients, as prior research suggested a relationship between physician fatigue and medical … common for interns, and working extended shifts is associated with an increased risk of percutaneous
injuries … sleep-deprivation-and-clinical-performance
https://psnet.ahrq.gov/issue/extended-work-duration-and-risk-self-reported-percutaneous-injuries-interns
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psnet.ahrq.gov/node/855103/psn-pdf
November 08, 2023 - health agencies, Medicare adverse events and the viability of
payment incentives as a strategy for medical … making-healthcare-safer-iv-continuous-updating-patient-safety-harms-and-practices
https://psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half-falls-major-injury-and-hospitalization-among