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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - Breakage of a PICC Line
April 1, 2009
Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences of PICC line breakage.
Understand the risk factors for PICC line breakage.
Understand the treatment options in…
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - steps include the following:
Establish institutional support for the initiative and ensure adequate organization
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - For allergies, medications, and medical problems, most
organizations require that a health care provider
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Systems level Interventions
Pharmacy-led medication reconciliation
There are several changes that organizations
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - I believe the professional organizations, from medical practices to hospital to medical societies and
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - Take-Home Points
Health care organizations must have systems in place to prevent inevitable errors
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - In addition, health care organizations that receive federal funds—most do in the form of public insurance
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psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - hospital-acquired pressure ulcers, with the possibility of associated fines.( 7 ) Lastly, non-profit health care organizations
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - utilization, and thus to accommodate more patients while improving the financial performance of their organizations
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - part of National Patient Safety Goal (NPSG) 15.01.01
for medical hospitals and behavioral health care organizations
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Feasibility and
Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - accessible to patients, and my hope is that over the next several years that
the other professional organizations
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psnet.ahrq.gov/node/73145/psn-pdf
April 28, 2021 - KH: When you're working with these organizations, what is your role within the in-center program?
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - back-tracking from erroneous choices.( 14 )
Given how common picklist errors are, there are mechanisms for organizations
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Early Warning Systems
Multiple institutions and organizations have developed protocols and mechanisms
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - For organizations that identify a need to focus on teamwork, collaboration, and communication, TeamSTEPPS
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psnet.ahrq.gov/node/33756/psn-pdf
October 01, 2013 - pushback from the manufacturers who were concerned about the focus on these issues,
but in the end the organization
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - The Colorectal Cancer Screening Committee of the World Endoscopy Organization has standardized the definition … 'Right-sided lesions and interval cancers,' Colorectal Cancer Screening Committee, World Endoscopy Organization