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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Research has recently shown benefit for monitoring opioid
withdrawal using objective measures such as … the Clinical Opioid Withdrawal Scale (COWS).(7) An
objective measure was not used in this case, but … The Clinical Opioid Withdrawal Scale (COWS) can be a useful objective measure of opioid
withdrawal.
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psnet.ahrq.gov/node/50885/psn-pdf
February 12, 2020 - Impact of staff turnover during cardiac surgical
procedures.
February 12, 2020
Bloom JP, Moonsamy P, Gartland RM, et al. Impact of staff turnover during cardiac surgical procedures. J
Thorac Cardiovasc Surg. 2019. doi:10.1016/j.jtcvs.2019.11.051.
https://psnet.ahrq.gov/issue/impact-staff-turnover-during-cardiac-su…
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psnet.ahrq.gov/node/39611/psn-pdf
June 16, 2010 - Avoidable mistakes rise despite hospital efforts.
June 16, 2010
Colliver V.
https://psnet.ahrq.gov/issue/avoidable-mistakes-rise-despite-hospital-efforts
This newspaper article details the incidence of retained foreign objects after surgery in California hospitals
and explains how fines collected by the state will…
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psnet.ahrq.gov/node/44290/psn-pdf
April 10, 2023 - Retained surgical sponge (gossypiboma) and other
retained surgical items: prevention and management.
April 10, 2023
Copeland AW. UpToDate. April 10, 2023.
https://psnet.ahrq.gov/issue/retained-surgical-sponge-gossypiboma-and-other-retained-surgical-items-
prevention-and
Retained surgical items are rare and potent…
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psnet.ahrq.gov/node/837961/psn-pdf
August 31, 2022 - Risk reduction strategy to decrease incidence of retained
surgical items.
August 31, 2022
Kaplan HJ, Spiera ZC, Feldman DL, et al. Risk reduction strategy to decrease incidence of retained
surgical items. J Am Coll Surg. 2022;235(3):494-499. doi:10.1097/xcs.0000000000000264.
https://psnet.ahrq.gov/issue/risk-reduc…
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psnet.ahrq.gov/issue/preventable-errors-operating-room-part-2-retained-foreign-objects-sharps-injuries-and-wrong
April 25, 2018 - Review
Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery.
Citation Text:
Dagi F, Berguer R, Moore S, et al. Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surg…
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - We have kind of that dual objective of a typical industrial engineering objective to improve quality … and productivity, efficiency, and so on, but also an objective that you would find in other disciplines … The dual objective that I was talking about earlier in the definition of HFE is part of our SEIPS models
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psnet.ahrq.gov/node/837025/psn-pdf
May 04, 2022 - Central venous catheter guidewire retention: lessons
from England's never event database.
May 4, 2022
Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from
England's never event database. J Patient Saf. 2022;18(2):e387-e392.
doi:10.1097/pts.0000000000000826.
https:/…
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - risk factors and identifying oversedation. 6 This assessment should encompass both subjective and objective … Objective data such as heart rate, blood pressure, and respiratory rate illustrate the patient’s cardiorespiratory
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psnet.ahrq.gov/node/41159/psn-pdf
September 29, 2017 - A nurse-led approach to developing and implementing a
collaborative count policy.
September 29, 2017
Norton EK, Micheli AJ, Gedney J, et al. A nurse-led approach to developing and implementing a
collaborative count policy. AORN J. 2012;95(2):222-7. doi:10.1016/j.aorn.2011.11.009.
https://psnet.ahrq.gov/issue/nurse…
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psnet.ahrq.gov/node/43086/psn-pdf
March 26, 2014 - International Comparisons: A Focus on Quality of Care.
March 26, 2014
Ottawa, ON: Canadian Institute for Health Information; January 23, 2014.
https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care
This report compared the quality of care in Canada with 34 other countries to identify areas in whi…
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psnet.ahrq.gov/node/41978/psn-pdf
January 16, 2013 - Surgical complications: disclosing adverse events and
medical errors.
January 16, 2013
Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad
Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008.
https://psnet.ahrq.gov/issue/surgical-complications-disclosing-advers…
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - The objective of the report is to provide information to providers,
administrators, researchers, and
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/node/44983/psn-pdf
April 20, 2016 - Back to basics: counting soft surgical goods.
April 20, 2016
Spruce L. Back to Basics: Counting Soft Surgical Goods. AORN J. 2016;103(3):298-301; quiz 302-3.
doi:10.1016/j.aorn.2015.12.021.
https://psnet.ahrq.gov/issue/back-basics-counting-soft-surgical-goods
Despite heightened awareness of hazards associated with…
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psnet.ahrq.gov/issue/natural-history-retained-surgical-items-supports-need-team-training-early-recognition-and
January 18, 2013 - Study
Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.
Citation Text:
Stawicki P, Cook CH, Anderson HL, et al. Natural history of retained surgical items supports the need for team training, early recognition, and pr…
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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
Citation Text:
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/node/45332/psn-pdf
August 27, 2018 - Guideline implementation: prevention of retained surgical
items.
August 27, 2018
Fencl JL. Guideline Implementation: Prevention of Retained Surgical Items. AORN J. 2016;104(1):37-48.
doi:10.1016/j.aorn.2016.05.005.
https://psnet.ahrq.gov/issue/guideline-implementation-prevention-retained-surgical-items
Although i…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - presence of preexisting medical conditions such as chronic hypertension or diabetes.( 2,4 ) The primary objective … This objective is achieved by formulating a management plan that takes into consideration severity of