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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - diagnosed with a rotator cuff injury and
underwent left shoulder surgery
• Four months later, the orthopedic … evaluation”
5
Case Details
• The radiologist’s report along with the images were sent to the
orthopedic … surgeon’s office the same day
• The orthopedic surgeon independently read and interpreted
the same … was no mention of the soft tissue density nor was any
follow-up study ordered
• The patient saw the orthopedic … such as surgery
13
“What We’ve Got Here is a Failure to Communicate” (3)
• In this case, the orthopedic
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/018-ss-importance-ssi-mrsa-prevention.pptx
April 01, 2025 - Is a Major Cause of SSI
S. aureus is the leading causative organism of SSIs.6
Overall: 17.5 percent
Orthopedic … decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic … surgery: systematic review and meta-analysis. … surgery: systematic review and meta-analysis. … surgery: systematic review and meta-analysis.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/009-ss-evidence-decolonization-fg.docx
April 01, 2025 - examining some surgery types that are high risk for MRSA infections and SSIs, specifically cardiac and orthopedic … surgeries, Staphylococcus aureus is the most frequently isolated SSI pathogen among spinal fusion and … hip or knee prosthesis (both are included in the orthopedic table) and among cardiac surgeries. … as part of the decolonization process was the Study to Optimally Prevent SSIs in Select Cardiac and Orthopedic … This was a pragmatic study in 20 U.S. hospitals from 2013–2014, which included cardiac surgeries and orthopedic
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh3.html
April 01, 2018 - The review percentages for the two orthopedic surgeries changed little between the two years-for hip
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psnet.ahrq.gov/issue/healthcare-simulation-nursing-practice
July 08, 2020 - January 23, 2019
Quality, Value, and Patient Safety in Orthopedic Surgery.
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ce.effectivehealthcare.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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www.qualitymeasures.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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www.talkingquality.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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www.cahps.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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www.cpsi.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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patientregistry.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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teamstepps.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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cahps.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
healthcare411.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
talkingquality.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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monahrq.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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ahrqpubs.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
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www.innovations.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
www.healthcare411.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological
-
www.monahrq.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - occurred in the services and nursing units (a 50% reduction in general surgery, a 57% reduction in orthopedic … surgery, and an 80% reduction in the medical surgical nursing unit serving the orthopedic, gynecological