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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - CME activity which has been mitigated through UC Davis Health, Office of Continuing Medical Education procedures … , and tube displacement. 4 Persistent bleeding from venous sources injured during the tracheostomy procedure … the first tracheostomy tube change is often based on the judgment of the physician who performed the procedure … the type of placement is unknown, no change should occur within the first five to seven days of the procedure … and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods
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psnet.ahrq.gov/innovations
February 26, 2025 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery … One otolaryngology (ENT) clinic developed a surgical marking procedure deemed practicable and useful … to improve outcomes and patient safety has long been a problem in the US healthcare system. 1 Many methods … A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment … One otolaryngology (ENT) clinic developed a surgical marking procedure deemed practicable and useful
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - ., peritoneal vs. hemodialysis) may also have different risks associated with the complexity of the procedure … their care partner may feel apprehensive about assuming the responsibility for performing the dialysis procedure … Typically, home dialysis programs have in place appropriate safeguard procedures to prevent, mitigate … Is there any real-time monitoring during the dialysis procedure? … August 21, 2024
The Safe Home Care Intervention Study: implementation methods and effectiveness
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - 14, 2014
A dynamic risk management approach for reducing harm from invasive bedside procedures … September 22, 2021
Perspective
Aviation Safety Methods:
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - benefits of IV insulin drips seen in the ICU, we believe that we are at equipoise, and thus the two methods … infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - A physician performed an outpatient dilation procedure for a suspected postoperative stricture. … Two days after this procedure, the patient was treated for dehydration in an outpatient clinic. … patient’s health condition.
12
12
Background (4)
In the case presented, the patient underwent a procedure … The procedure appears to have had its intended effect: the patient lost a significant amount of weight … input from all members of the diagnostic team, and it is imperative that health care systems identify methods
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psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - updates-management-high-risk-pulmonary-embolism
Case Objectives
Review common risk factors, typical presentation, methods … The procedure
went well, and the patient was monitored in the ICU after the procedure. … A CDT procedure
is typically performed by an interventional cardiologist, interventional radiologist … After the patient's successful catheter-directed thrombolysis procedure, the vignette notes that an explicit
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psnet.ahrq.gov/periodic-issue/periodic-issue-308
September 29, 2021 - This mixed-methods study surveyed medical residents about their well-being, coping strategies, and support … Study
Why an open disclosure procedure is and is not followed after an avoidable adverse … During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart
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psnet.ahrq.gov/periodic-issue/periodic-issue-399
July 31, 2023 - A prospective, mixed methods study in primary care. … The most frequent never events were wrong site or wrong patient surgery, wrong surgical procedure, and … , the order was not communicated verbally and he was allowed to eat, leading to postponement of the procedure
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - For example, the FDA [Food and Drug Administration] may decide that new,
complex, and high-risk procedures … You can imagine, for example, in pediatric cardiac surgery—where you have unusual
anatomy—that the procedure … You could imagine savvy marketers of these new
technologies saying, "Your surgeon will practice the procedure … We are interested in using cognitive engineering methods to really get at
what people are thinking when
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - KH : That idea really resonates - bringing together the culture and person and family engagement as methods
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - KH : That idea really resonates - bringing together the culture and person and family engagement as methods
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - • MHS IV Methods
➢ Searched PubMed & Cochrane Library for systematic reviews & primary
studies (2018 … for reducing opioid
dosages, but no conclusions on clinical outcomes or impact on pain
• MHS IV Methods
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psnet.ahrq.gov/periodic-issue/periodic-issue-337
April 27, 2022 - supported the family during the resuscitation in numerous ways, such as explaining jargon and medical procedures … complications associated with IO lines, the importance of anticipating procedural complications, and methods
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding … perspectives on the adoption of OR black box technology and simulations to improve patient safety: a multi-methods
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - program
coordinator, communication channels for coordination between providers, standardized reporting
procedures … , measures of progress, and methods for data collection
A protocol for scheduling home visits.
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psnet.ahrq.gov/node/33720/psn-pdf
November 01, 2011 - has not done anything to support the new skills, and of course with time, people revert back to
old methods … What are your procedures? What types of signals is top leadership sending? … What are the policies and the procedures, etc.?" And that's
where they say, "Oh, we didn't know.
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - associated with
intraosseous (IO) lines, the importance of anticipating procedural
complications, and methods … • The case reminds us that even straightforward procedures, like
vascular access, are not without … • Many procedures and medical interventions are associated with known
risks and complications, including … Intraosseous infusion: A re-discovered procedure as an alternative for pediatric vascular access.