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61. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
    psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
    August 16, 2023 - of central venous cannulation in children and adults, the experience of the proceduralist and a low number … Perhaps equally troubling as the excessive number of cannulation attempts in this case is the delay in … facial, or external jugular vein, or ultrasound guidance should have been used to help minimize the number … In addition, the number of cannulation attempts by the trainee should have been limited, and care providers … anticipated risks and strategies to reduce them, including shared understandings about the allowable number

62. Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study. | PSNet
    psnet.ahrq.gov/issue/potentially-severe-incidents-during-interhospital-transport-critically-ill-patients
    October 26, 2022 - This study compared the number of self-reported (to the study team) safety incidents during interhospital … transport and the number of incidents submitted to the hospital’s reporting system. … July 13, 2022 Monitoring preventable adverse events and near misses: number and type

63. Spotlight Case September 2006 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
    September 01, 2006 - including RNs, NPs, and MDs, must sign out patients Housestaff duty-hour restrictions have increased the number … Signout: Numbers After duty-hours restrictions, signouts increased by 40% Average number of times a … resident signs out per month: 300 Estimated total number of signouts per day (including all health … care providers) in large academic hospital: 4,000 Estimated total number of signouts per year in a … cross-coverage in managing anticipated problems ANTICipate Administrative data Name, MR number

64. Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study. | PSNet
    psnet.ahrq.gov/issue/impact-work-schedules-senior-resident-physicians-patient-and-resident-physician-safety
    May 25, 2022 - Nearly 5,000 PGY2+ residents reported the number of hours worked, patient safety outcomes, and resident … September 4, 2019 Effect of restriction of the number of concurrently open records in … September 23, 2020 A national survey assessing the number of records allowed open in

65. In Conversation With... Barbara Drew, RN, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
    May 01, 2016 - But I had absolutely no clue of the staggering number of alarms that we would find in our intensive … When I saw that number, I thought there was a mistake—but there wasn't. … Nurses had told us that there were and that it was becoming background noise to them, but this number … number that people say. … By reducing the number of waveform artifacts, one can decrease the number of false alarms.

66. Medication reconciliation in oncological patients: a randomized clinical trial. | PSNet
    psnet.ahrq.gov/issue/medication-reconciliation-oncological-patients-randomized-clinical-trial
    March 09, 2022 - randomized trial found that a pharmacist-led medication reconciliation intervention was able to reduce the number … February 27, 2019 Does a checklist reduce the number of errors made in nurse-assembled … November 9, 2022 Correlation between the number of patient-reported adverse events, adverse

67. Medication errors at hospital admission and discharge: risk factors and impact of medication reconciliation process to improve healthcare. | PSNet
    psnet.ahrq.gov/issue/medication-errors-hospital-admission-and-discharge-risk-factors-and-impact-medication
    November 10, 2021 - Most medication errors were omissions and risk of error increased with the number of medications. … November 9, 2022 Cleaning up the discharge process: a number of components—and personnel—are … November 16, 2022 Correlation between the number of patient-reported adverse events,

68. Indication alerts to improve problem list documentation. | PSNet
    psnet.ahrq.gov/issue/indication-alerts-improve-problem-list-documentation
    February 22, 2023 - July 28, 2021 Effect of restriction of the number of concurrently open records in an … May 29, 2019 A national survey assessing the number of records allowed open in electronic … June 8, 2016 Effect of number of open charts on intercepted wrong-patient medication … July 15, 2020 Association between limiting the number of open records in a tele-critical … December 14, 2022 Correlation between the number of patient-reported adverse events,

69. Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart | PSNet
    psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
    May 01, 2024 - Evidence Rating Moderate: The evidence consists of pre- and post-implementation comparisons of the number … In a substantial number of these cases, the error stems from orders being entered into the wrong patient's … percent of the time. 3 Although an infrequent occurrence, these mistakes can result in a meaningful number … The impetus for this program came in 2009, when organizational leaders responded to a number of errors … the problem, including limiting the number of records a provider can have open at the same time.

70. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
    February 01, 2013 - She followed standard procedure and tried to call the patient using the contact number in the EMR. … patient executing a treatment plan That is what occurred in this case * * Follow-up Errors A number … type of malpractice claim ¼ of these claims concern failure to follow up test results There are a number … tracking systems to be sure results are reviewed and acted on * * * Take-Home Points A significant number

71. In Conversation With… Richard Hoppmann, MD | PSNet
    psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
    June 01, 2018 - We needed to reach a critical mass of supporters of ultrasound in education for a number of reasons. … From 2006 to 2016, there has been a tremendous increase in the number of publications related to ultrasound … RH : We have good data on a number of well-documented examples. One would be for renal stones. … We do a number of things to help newcomers get up to speed such as an ultrasound boot camp. … a limited number of ultrasound exams and billing for them.

72. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet
    psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
    March 01, 2015 - The commonly used HSMR is a ratio of the observed number of in-hospital deaths to the number expected … Sensitivity may be increased by enlarging the number of evaluable deaths by including those occurring … BJ : At Bristol we spent a long time trying to measure morbidity, because quite a number of children … It's just the difference between the number of deaths that you get in the hospital and the number that … December 16, 2015 New mother number 14.

73. Safety Considerations in Building a Point-of-Care Ultrasound Program | PSNet
    psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
    June 01, 2018 - 2001 survey of physicians on the relative importance of 30 medical innovations ranked ultrasound as Number … 11 (CT and MRI shared the Number 1 spot).( 3 ) AHRQ has listed the "use of real-time ultrasound guidance … RH : We have good data on a number of well-documented examples. One would be for renal stones. … We do a number of things to help newcomers get up to speed such as an ultrasound boot camp. … a limited number of ultrasound exams and billing for them.

74. Serious adverse drug events reported to the FDA: analysis of the FDA Adverse Event Reporting System 2006–2014 database. | PSNet
    psnet.ahrq.gov/issue/serious-adverse-drug-events-reported-fda-analysis-fda-adverse-event-reporting-system-2006
    December 15, 2010 - Over the 9-year study period, the number of serious ADEs reported doubled and a small number of medications … accounted for a significant number of serious and fatal ADEs.

75. In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges | PSNet
    psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
    April 24, 2024 - I think that’s the number one priority. … A Worriesome Drop in the Number of Young Nurses. … https://www.healthaffairs.org/content/forefront/worrisome-drop-number-young-nurses . 4 Dill J, Duffy … In 1982, there were about one million registered nurses (RNs) in the United States; by 2020, that number … A worrisome drop in the number of young nurses. Health Affairs Forefront blog. April 13, 2022.

76. Mark My Tooth | PSNet
    psnet.ahrq.gov/web-mm/mark-my-tooth
    June 01, 2014 - Unfortunately, no clear trends were identified that would help reduce the number of wrong-site surgeries … , and the number of claims has stayed fairly constant despite risk management seminars and online courses … This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research … December 16, 2015 New mother number 14.

77. In Conversation with...Atul Gawande, MD, MA, MPH | PSNet
    psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
    September 01, 2007 - But it's very clear that a great number of centers are very upset about this having gone public. … If this is a process that is truly necessary for everyone, then number one, we'll make it good enough … that it's acceptable for every patient, and number two, it will be a burden shared. … And I always tell them, number one, I won't write about you without your permission. … Number two is that the answer is no, because what I really feel I struggle for are ideas.

78. Clinical and economic impacts of explicit tools detecting prescribing errors: a systematic review. | PSNet
    psnet.ahrq.gov/issue/clinical-and-economic-impacts-explicit-tools-detecting-prescribing-errors-systematic-review
    January 12, 2022 - Due to the low number of RCT studies evaluating these tools, additional studies are warranted. … August 4, 2021 Association between limiting the number of open records in a tele-critical … December 14, 2022 Correlation between the number of patient-reported adverse events,

79. Performance of 3 sets of criteria for potentially inappropriate prescribing in older people to identify inadequate drug treatment. | PSNet
    psnet.ahrq.gov/issue/performance-3-sets-criteria-potentially-inappropriate-prescribing-older-people-identify
    January 12, 2022 - as diagnostic tools to identify inadequate drug treatment in older patients compared to counting the number … February 8, 2023 Correlation between the number of patient-reported adverse events, adverse … November 16, 2022 Correlation between the number of patient-reported adverse events,

80. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
    psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
    March 29, 2023 - Due to the extremely high number of drug administration episodes in the operating room, it is not feasible … Due to the very large number of medication administration episodes in the operating room it is not usual … anesthesia professionals that include sterility, convenience, and perceived safety. 13 Limiting the number … attention when drawing up medications Prefilled syringes reduce dilution and labelling errors Limit the number … Anesthesia Safety Foundation Newsletter 1987;2(4) This project was funded under contract number