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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Was the medical testing associated with the error adequate? … Medical staff should have a detailed list of blood tests to be performed, blood volume samples, who should … A bar code embedded with 4 unique identifiers (infant surname, medical chart number, date of birth, and … 2023
Ensuring effective care transition communication: implementation of an electronic medical … September 26, 2016
Prevalence of medication administration errors in two medical units
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psnet.ahrq.gov/issue/mixed-method-study-practitioners-perspectives-issues-related-ehr-medication-reconciliation
September 23, 2020 - Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … December 30, 2014
How context affects electronic health record–based test result follow-up
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psnet.ahrq.gov/issue/electronic-health-record-interoperability-why-electronically-discontinued-medications-are
August 25, 2021 - March 17, 2021
Why test results are still getting "lost" to follow-up: a qualitative … June 24, 2020
Reporting of death in US Food and Drug Administration medical device adverse
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psnet.ahrq.gov/issue/prevalence-potentially-inappropriate-medication-use-older-adults-living-nursing-homes
May 04, 2022 - artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test … September 9, 2020
An objective framework for evaluating unrecognized bias in medical
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psnet.ahrq.gov/issue/assessment-health-information-technology-related-outpatient-diagnostic-delays-us-veterans
June 24, 2020 - key diagnostic information, technical problems, data entry problems, and failure of a system to track test … June 24, 2020
Toward safer health care: a review strategy of FDA medical device adverse
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - At Dartmouth-Hitchcock Medical Center, failures of team communication were identified in 61% of the 42 … At Dartmouth, simulated pediatric sedation events are conducted to "stress test" various clinical settings … Blike, MD Director, Dartmouth Medical Interface Laboratory Associate Professor of Anesthesiology and … Clinician-patient communication
N/A in this case
-
Availability and accuracy of test … Delayed transmission
Laboratory test results relevant to therapeutic decision are "lost" for several
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psnet.ahrq.gov/issue/effect-medication-reconciliation-elderly-patients-hospital-discharge
February 04, 2009 - June 20, 2012
Psychological safety during the test of new work processes in an emergency … October 27, 2021
Discrepancies between in-home interviews and electronic medical records
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psnet.ahrq.gov/issue/minimising-treatment-associated-risks-systemic-cancer-therapy
December 22, 2021 - May 25, 2022
Why test results are still getting "lost" to follow-up: a qualitative study … October 29, 2017
View More
See More About The Topic
Pharmacists
Medical
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psnet.ahrq.gov/issue/patient-identification-and-tube-labelling-call-harmonisation
April 29, 2020 - December 11, 2024
Prevalence of medication administration errors in two medical units … March 3, 2011
Is the test result correct?
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psnet.ahrq.gov/issue/information-distortion-physicians-diagnostic-judgments
April 07, 2021 - February 22, 2012
The frequency of missed test results and associated treatment delays … April 14, 2011
Factors influencing preceptors' responses to medical errors: a factorial
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - Framing effects, anchoring, and overreliance on test results are
potential sources of diagnostic error … As in this case, inpatients may be located in diverse areas of
the hospital including general medical … Test with eyes open. In
case of visual defect, ensure testing is done in intact
visual field. … In case
of blindness, test by having the patient touch nose from
extended arm position.
0 = Absent … Only sensory loss
attributed to stroke is scored as abnormal and the
examiner should test as many body
-
psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Count Retention Case
RNs call sponge count incorrect
NO sponge in patient
FALSE Positive
Miscount
TEST … call sponge count correct
NO sponge in patient
TRUE Negative
The sponge “count” can be considered a test … the most
dangerous scenario because everyone thinks the patient is safe (based on the false negative test … Spartan Medical launches the Melzi sharps finder to help hospitals avoid retained surgical sharps
miscounts … Avoiding retained surgical items at an academic medical
center: sustainability of a surgical quality
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - Nearly every test, medication, or procedure has the potential to cause adverse effects. … How Can We Address Medical Overuse? … Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging. … RG : Fear of medical malpractice drives overuse. … Overuse is causing medical malpractice suits.
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psnet.ahrq.gov/issue/simulation-systems-testing-program-using-hfmea-methodology-can-effectively-identify-and
January 03, 2017 - Air medical transport carries unique patient safety risks. … , 2021
A multisite study of interprofessional teamwork and collaboration on general medical
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psnet.ahrq.gov/issue/effectiveness-electronic-differential-diagnoses-ddx-generators-systematic-review-and-meta
October 14, 2015 - The effect on actual clinician behaviors—such as test ordering, clinical outcomes, and cost—is unclear … February 17, 2021
Prevalence, severity, and nature of preventable patient harm across medical
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psnet.ahrq.gov/issue/types-and-origins-diagnostic-errors-primary-care-settings
January 19, 2012 - This study used previously developed trigger tools to screen the electronic medical record to identify … October 31, 2014
A virtual breakthrough series collaborative for missed test results:
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psnet.ahrq.gov/issue/patients-partners-how-involve-patients-and-families-their-own-care
July 12, 2006 - From the Same Author(s)
Getting Results: Reliably Communicating and Acting on Critical Test … July 22, 2020
Disclosing Medical Errors: A Guide to an Effective Explanation and Apology
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition
May 18, 2016 - July 22, 2020
Disclosing Medical Errors: A Guide to an Effective Explanation and Apology … April 24, 2007
Getting Results: Reliably Communicating and Acting on Critical Test Results
-
psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - described in surgical patients who abruptly bled into their pericardium.(7) This triad is seldom
seen in medical … the absence of this sign
makes cardiac tamponade unlikely.(11)
Echocardiography is the non-invasive test … Cardiac tamponade in medical patients is a continuum of hemodynamic effects and can progress
slowly … reference standard for the detection of cardiac
tamponade, the pulsus paradoxus can be a helpful bedside test … Christopher Roy, MD Assistant Professor of Medicine Harvard Medical School
https://psnet.ahrq.gov
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psnet.ahrq.gov/issue/receptionist-input-quality-and-safety-repeat-prescribing-uk-general-practice-ethnographic
March 23, 2022 - November 9, 2015
Reducing diagnostic error through medical home-based primary care reform … October 10, 2012
Management of test results in family medicine offices.