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Showing results for "operating".

4761. Hypoxemia after Emergency Intubation | PSNet
      psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
      March 24, 2019 - When patients are transported to radiology, the intensive care unit or the operating room, the ETT may … WebM&M Cases Unintentional Ketamine Overdose in the Operating … : Fluid administration errors in the operating room.

4762. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
      January 01, 2024 - elbow wounds—or at least to appreciate that more thorough evaluation of the wound was required in the operating … circumstances. 51 Take-Home Points (2) 52 Have a low threshold for surgical exploration of a wound in an operating

4763. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
      April 01, 2006 - During this time, the surgeon began to yell at members of the operating room (OR) team for a variety

4764. Lost in Transition | PSNet
      psnet.ahrq.gov/web-mm/lost-transition
      November 17, 2010 - Case Objectives Provide an overview of transitions in continuously operating industries Review … For example, a trauma nurse asks if anyone has informed the operating room (OR) of a patient’s pending

4765. Crossing the Line | PSNet
      psnet.ahrq.gov/web-mm/crossing-line
      December 01, 2012 - At the end of the procedure, the operating physician reported excessive bleeding from the catheter site

4766. Procedure Complications – Who is Responsible for Follow up? | PSNet
      psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
      July 31, 2023 - April 1, 2003 View More See More About The Topic Hospitals Operating

4767. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet
      psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
      March 15, 2023 - WebM&M Cases Medication Handling and Compounding Errors in the Operating

4768. WebM&M: Case Studies | PSNet
      psnet.ahrq.gov/webmm-case-studies
      March 25, 2025 - Departments (149) Intensive Care Units (82) Labor and Delivery (23) Operating … The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with

4769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45987/psn-pdf
      April 26, 2017 - Using simulation to prepare nursing staff for the move to a new building. April 26, 2017 Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329. https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…

4770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867849/psn-pdf
      February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

4771. Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. | PSNet
      psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment
      September 05, 2012 - Book/Report Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. Citation Text: Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. Tuc…

4772. In Conversation With… Susan Haas, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
      March 01, 2019 - They again had a completely different operating system and set of assumptions and goals. … So that meant trying to understand different operating systems, resources, and culture as we tried to … Permanente) were all one group, and that was deeply embedded into the DNA of the doctors as well as the operating … SH : My opinion is that every hospital develops its own culture and its own operating system.

4773. Aviation Safety Methods: Quickly Adopted but Questions Remain | PSNet
      psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
      January 01, 2006 - what circumstances and how is it useful for a medical student to question a surgeon's decision in the operating … may be effective where the health care setting or processes most resemble a cockpit environment: the operating … it wasn't necessarily true, in large part because the fixed teams actually start to ignore standard operating … Conversely, in the emergency department or operating room, normally the team is all working together.

4774. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - surgeon placed the PEG tube in the ICU using the “pull technique” (i.e., via the mouth) because an operating … • When he contacted the operating surgeon, he learned that the plan was to revise the PEG tube via … end of her inpatient stay and recommended outpatient open gastrostomy tube revision, but neither the operating … AND ALTERNATIVE APPROACHES 20 Risk Factors and Alternative Approaches (1) • In many locations, operating

4775. In Conversation with…Jack Barker, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
      January 01, 2006 - it wasn't necessarily true, in large part because the fixed teams actually start to ignore standard operating … Conversely, in the emergency department or operating room, normally the team is all working together. … what circumstances and how is it useful for a medical student to question a surgeon's decision in the operating … may be effective where the health care setting or processes most resemble a cockpit environment: the operating

4776. Building a Safety Program in a Vast Health Care Network | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
      March 01, 2019 - They again had a completely different operating system and set of assumptions and goals. … So that meant trying to understand different operating systems, resources, and culture as we tried to … Permanente) were all one group, and that was deeply embedded into the DNA of the doctors as well as the operating … SH : My opinion is that every hospital develops its own culture and its own operating system.

4777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33687/psn-pdf
      August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care August 1, 2009 Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care Perspective Frontline health care providers are challen…

4778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33882/psn-pdf
      June 01, 2019 - For instance, the push for maximizing operating room (OR) utilization can sometimes lead OR coordinators

4779. Bloody BP Cuff | PSNet
      psnet.ahrq.gov/web-mm/bloody-bp-cuff
      June 21, 2016 - While the risk for patients and surgeons may be low in controlled settings (operating rooms and invasive … One study from the operating room revealed blood contamination of approximately 30% of surfaces tested

4780. Say It Again | PSNet
      psnet.ahrq.gov/web-mm/say-it-again
      January 31, 2020 - Communication failures in the operating room: an observational classification of recurrent types and … December 21, 2014 Incorrect surgical procedures within and outside of the operating room