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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - Standard radiographs may not be able to visualize the entire body part, requiring multiple panoramic-type … intravenous access sites is extremely important. … In general, drug dosing in obese patients can be based on ideal body weight (IBW), total body weight … Knowledge and attitudes of internal medicine residents. … Family practice residents' identification and management of obesity.
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psnet.ahrq.gov/issue/state-wide-initiative-standardize-compounding-oral-liquids-pediatrics
January 23, 2017 - Multi-use Website
State-Wide Initiative to Standardize the Compounding of Oral Liquids … certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents … December 22, 2021
Association of low-dose whole-body computed tomography with missed … injury diagnoses and radiation exposure in patients with blunt multiple trauma. … the Care Transitions Task Force of the New York State Anticoagulation Coalition.
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Standard radiographs may not be able to visualize the entire body part, requiring multiple panoramic-type … intravenous access sites is extremely important. … In general, drug dosing in obese patients can be based on ideal body weight (IBW), total body weight … Knowledge and attitudes of internal medicine residents. … Family practice residents' identification and
management of obesity.
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psnet.ahrq.gov/innovation/duke-pediatric-residency-safety-council
November 16, 2022 - sites, and produce patient safety leaders in the pediatric specialty. 2 The project supports learning … The morbidity and mortality conferences are larger discussions with the pediatric resident body and with … by residents from multiple specialties at Duke. … The council benefits from the participation of a wide group of residents. … Improving Patient Safety and Quality of Care: What Can Residents Do?
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psnet.ahrq.gov/issue/overdiagnosis-low-dose-computed-tomography-screening-lung-cancer
August 04, 2021 - From a research perspective, this study advances our understanding of the measurement of overdiagnosis … October 23, 2018
Readiness of US general surgery residents for independent practice. … of the clinical importance of changes to radiology reports. … July 15, 2010
Profiles in patient safety: misplaced femoral line guidewire and multiple … failures to detect the foreign body on chest radiography.
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psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients
July 15, 2014 - September 25, 2011
Response of practicing chiropractors during the early phase of the … Failure to Rescue
January 29, 2025
Risk factors and outcomes for foreign body … February 23, 2011
Multiple component patient safety intervention in English hospitals … : controlled evaluation of second phase. … February 23, 2011
Quality of traditional surveillance for public reporting of nosocomial
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psnet.ahrq.gov/periodic-issue/periodic-issue-425
February 28, 2024 - Both residents and attendings felt that IDR improved patient-centered care. … Residents reported IDR felt like just an additional task they had to perform despite also recognizing … Primary care residents' clinic rotations and their ultimate graduation may result in failure to follow … established this diagnosis was available in the electronic health record (EHR), but it was invisible to multiple … teams of providers across multiple phases of care due to issues related to the EHR itself, challenges
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - The time out was done with the two residents and the bedside
nurse and did not include verification … One
of the residents stepped away to confirm the patient’s identity in the electronic health record … should consist of confirming the correct procedure is planned on the
correct body part with the correct … on
maximizing every team member's potential, which is particularly important in the hospital where multiple … that is serious and usually avoidable, such as performing
a procedure on the wrong patient or wrong body
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - the PEG tube; (B)
skin marking on the external bolster kept at 2–5
cm depending on the patient’s body … peer review; many sites use
proactive review (double interpretation by separate radiologists) in addition … breakdown, that multiple
modes are needed. … This list
should be accessible to faculty, residents, and advanced practice practitioners (APPs), in … Because patient care handovers involving multiple specialists in multiple care environments have
been
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - The time out was done with the two residents and the bedside nurse and did not include verification of … One of the residents stepped away to confirm the patient’s identity in the electronic health record and … should consist of confirming the correct procedure is planned on the correct body part with the correct … on maximizing every team member's potential, which is particularly important in the hospital where multiple … that is serious and usually avoidable, such as performing a procedure on the wrong patient or wrong body
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psnet.ahrq.gov/node/74242/psn-pdf
January 07, 2022 - of use of a dual tracer
(Technicium-99 radiotracer and blue dye) decreases the surgeon’s ability to … Safety & Patient Safety Target
As noted here, breast surgeons, and surgeons in general, often perform multiple … Organization and required
by the Joint Commission Universal Protocol, which is the independent governing body … Surgical timeouts are universal in operating rooms; however, there are many multiple procedure surgeries … In cases where procedures
involving multiple care teams, whether in the operating room or because their
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psnet.ahrq.gov/node/49505/psn-pdf
March 01, 2006 - The patient’s abdomen was re-explored, at which time he began bleeding profusely from
multiple sites … , including the surgical wound, endotracheal tube, nasogastric tube, and intravenous catheter
sites, … The surgeon mechanically reinforced the anastomosis sites, but they continued to bleed. … He had received more than 20 units of blood products and was acidotic on multiple pressors. … The attending surgeon was known to have had multiple surgical complications in previous cases, and had
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - He subsequently experienced acute onset of shortness of breath associated with a "whistling sound" from … A tentative diagnosis of air
embolism was made, and computed tomography of the chest did not reveal … While small volumes of air entering the circulatory system can be absorbed by the body and
may be asymptomatic … Historically, CVC insertion has received attention as a procedure with multiple serious potential
risks … Prevents the
movement of
air into the
CVC tract
Promotes hemostasis, allowing the body to start to
-
psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - The night resident was called to the patient's bedside multiple times overnight
by the charge nurse … a
laparotomy, high risk of multiple operations, stoma formation, prolonged hospital stay, and, most … operations (e.g.,
gastrointestinal cancer surgery) and complex patients (e.g., those with high BMIs [body … An organizational culture that
emphasizes safety will work to flatten hierarchies, so that junior residents … and nursing staff will be
empowered to call on senior residents or attending physicians without any
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - The resident had never placed a subspecialty referral before and did not realize that there were multiple … result of a system that places both residents and patients in suboptimal positions. … A new and sobering body of research shows that practice patterns developed in residency persist many … Under the traditional model of ambulatory care, patients in our residents' practice received care of … The expectations of residents serving as primary care providers should be the same as those of all physicians—to
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psnet.ahrq.gov/node/49468/psn-pdf
December 16, 2004 - surgical procedures on the wrong body site (usually right versus left mistakes) or on the
wrong patient … , or the performance of the wrong procedure on the "correct" patient.(3) Some of these
occurrences have … This is not—as most
medical students and surgical residents are taught—simply an engagement between … From the time of the decision to perform surgery to transfer of the patient from the operating
room … to the post-anesthesia recovery room, multiple, seemingly simple processes—involving doctors,
nurses
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psnet.ahrq.gov/periodic-issue/periodic-issue-457
September 25, 2024 - transactional leadership formed the foundation for many definitions, though the authors advise adopting multiple … Residency training is a challenging experience, requiring residents to balance demanding educational … transactional leadership formed the foundation for many definitions, though the authors advise adopting multiple … WebM&M Cases
Spotlight Case
Errors in Managing an Open Wound of the Elbow Leading to Multiple … Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - surgical procedures on the wrong body site (usually right versus left mistakes) or on the wrong patient … , or the performance of the wrong procedure on the "correct" patient.( 3 ) Some of these occurrences … This is not—as most medical students and surgical residents are taught—simply an engagement between a … the post-anesthesia recovery room, multiple, seemingly simple processes—involving doctors, nurses, technicians … July 15, 2020
Checklist usage decreases critical task omissions when training residents
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psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - There's a whole body of literature looking at the development of mastery and the amount of
intentional … and results of comments rendered in the residents' survey, it appears that residents
are better rested … Handoffs are occurring at multiple levels in the system at the same
time. … All of that said, an extensive evolving body of literature indicates
that it is even more complicated … monitors the outcomes of residents, the residents'
impressions of their training, and the core administrative
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - He subsequently experienced acute onset of shortness of breath associated with a "whistling sound" from … 23% ( 3 ) to 50%.( 4 ) Because of the high mortality and the widespread use of CVCs, it is essential … While small volumes of air entering the circulatory system can be absorbed by the body and may be asymptomatic … Historically, CVC insertion has received attention as a procedure with multiple serious potential risks … Prevents the movement of air into the CVC tract Promotes hemostasis, allowing the body to start to form