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81. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
    January 01, 2020 - acidosis, and hyperglycemia) • Patient was admitted to the General Medicine service with a consult from Orthopedics … primary responsibility for a patient • In this case, it was unclear whether an Internal Medicine or Orthopedics … responsibility • Need to identify barriers to carrying out the Internal Medicine team’s intent • Orthopedic … surgery residents may not typically manage patients with medically complex issues; in this case, the … patient may have been better served on an internal medicine team with an orthopedics consult to streamline

82. Trial and error: learning from malpractice claims in childhood surgery. | PSNet
    psnet.ahrq.gov/issue/trial-and-error-learning-malpractice-claims-childhood-surgery
    March 09, 2022 - claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics … Operating Room Children's Hospitals Risk Managers Quality and Safety Professionals Orthopedic … Surgery View More

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49860/psn-pdf
    April 01, 2019 - The patient was admitted to the orthopedic surgery service to fix the fracture; the surgery was initially … All team members involved in the patient's care (internal medicine and/or geriatrics, orthopedics, emergency … comanagement service with either geriatrics or medicine in which both the medicine/geriatrics and orthopedics … Comanagement with either medicine or geriatrics and orthopedics reduces medical complications and improves … Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare

84. Patient safety: it takes a team. | PSNet
    psnet.ahrq.gov/issue/patient-safety-it-takes-team
    April 08, 2020 - December 24, 2014 Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic … More See More About The Topic Outpatient Surgery Operating Room Patients Orthopedic … Surgery Surgical Complications View More

85. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
    psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
    September 25, 2019 - Five days later, the bone pathologist responsible for the case contacted the orthopedic surgery service … surgery service or inform his colleagues about the status of the case or his concern for neoplasm. … the orthopedic surgery service contacted a supervising surgical pathologist, requesting a final diagnosis … surgery team that the patient’s fracture was secondary to osteosarcoma. … surgery team was longer than ideal.

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37944/psn-pdf
    April 11, 2011 - Identification of adverse events at an orthopedics department in Sweden. … Identification of adverse events at an orthopedics department in Sweden. … https://psnet.ahrq.gov/issue/identification-adverse-events-orthopedics-department-sweden This study … methods of error detection to determine the incidence of adverse events in patients discharged from an orthopedics … https://psnet.ahrq.gov/issue/identification-adverse-events-orthopedics-department-sweden

87. Impact of AHRQ’s Patient Safety Tools: Challenge Competition | Agency for Healthcare Research and Quality
    www.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

88. Deficiencies in electronic medical record inpatient list capabilities negatively impact patient safety, resident education, and wellness. | PSNet
    psnet.ahrq.gov/issue/deficiencies-electronic-medical-record-inpatient-list-capabilities-negatively-impact-patient
    October 19, 2022 - Following a change in EHR vendors, residents in 1 orthopedics department were no longer able to automate … October 1, 2009 View More See More About The Topic Hospitals Orthopedic … Surgery Residents and Fellows Electronic Health Records

89. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37469/psn-pdf
    January 16, 2008 - Towards the reduction of medication errors in orthopedics and spinal surgery: outcomes using a pharmacist-led … Towards the reduction of medication errors in orthopedics and spinal surgery: outcomes using a pharmacist-led … https://psnet.ahrq.gov/issue/towards-reduction-medication-errors-orthopedics-and-spinal-surgery- outcomes-using-pharmacist … https://psnet.ahrq.gov/issue/towards-reduction-medication-errors-orthopedics-and-spinal-surgery-outcomes-using-pharmacist … https://psnet.ahrq.gov/issue/towards-reduction-medication-errors-orthopedics-and-spinal-surgery-outcomes-using-pharmacist

90. AHRQ Safety Program for MRSA Prevention: Targeting SSI
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/002-ss-antimicrobial-prophylaxis-part-1.pptx
    April 01, 2025 - surgery Cardiac surgery | 9 AHRQ Safety Program for MRSA Prevention | Surgical Services Antimicrobial … Prophylaxis Part 1 9 Cefazolin Covers Expected Microbiology* *expected microbiology of cardiac and orthopedic … surgeries | 10 AHRQ Safety Program for MRSA Prevention | Surgical Services Antimicrobial Prophylaxis … decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic … surgery: systematic review and meta-analysis.

91. Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. | PSNet
    psnet.ahrq.gov/issue/sustained-improvement-quality-patient-handoffs-after-orthopaedic-surgery-i-pass-intervention
    June 15, 2022 - In this study, researchers modified the I-PASS tool for use in orthopedic surgery and assessed the impact … See More About The Topic Hospitals Operating Room Quality and Safety Professionals Orthopedic … Surgery Discontinuities, Gaps, and Hand-Off Problems View More

92. Medical errors in orthopaedics. Results of an AAOS member survey. | PSNet
    psnet.ahrq.gov/issue/medical-errors-orthopaedics-results-aaos-member-survey
    August 04, 2021 - The majority of practicing orthopedic surgeons in this study had witnessed a medical error within the … More About The Topic Operating Room Risk Managers Quality and Safety Professionals Orthopedic … Surgery Medication Errors/Preventable Adverse Drug Events View More

93. 089-Or-Traffic-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/089-or-traffic-fg.docx
    April 01, 2025 - The first is a study conducted in orthopedic trauma implant surgeries in Sweden. … In this example, the orthopedic surgery CUSP team at a local hospital reviewed their SSI rates and discovered … The CUSP team decided to complete the Learning From Defects tool with a focus on OR traffic in the orthopedic … They had already determined there was an increase in SSIs in the orthopedic surgery population. … The CUSP team collected data on door openings for 10 orthopedic cases and noted that door openings ranged

94. Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout? | PSNet
    psnet.ahrq.gov/issue/does-seasonal-variation-orthopaedic-trauma-volume-correlate-adverse-hospital-events-and
    May 25, 2022 - This study explored seasonal variation in workload in an orthopedic trauma service at one Level 1 trauma … View More See More About The Topic Residents Operating Room Educators Orthopedic … Surgery Fatigue and Sleep Deprivation View More

95. Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections. | PSNet
    psnet.ahrq.gov/issue/clinical-pathway-adherence-and-missed-diagnostic-opportunities-among-children-musculoskeletal
    November 08, 2023 - Misinterpretation of laboratory results was a critical contributor to MDO by both pediatric emergency providers and orthopedic … The Topic Emergency Departments Emergency Medicine Pathology and Laboratory Medicine Orthopedic … Surgery Diagnostic Test Interpretation Error View More

96. Bay Area Community Informatics Project | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/bay-area-community-informatics-project
    January 01, 2023 - Medically Underserved Populations Rural Populations Type of Care Acute Care Orthopedics … health care organizations including a community hospital, two multi-specialty primary care clinics, an orthopedic

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36793/psn-pdf
    August 26, 2011 - Patient safety in Taiwan: a survey on orthopedic surgeons. … Patient safety in Taiwan: a survey on orthopedic surgeons. J Formos Med Assoc. 2007;106(3):212-6. … https://psnet.ahrq.gov/issue/patient-safety-taiwan-survey-orthopedic-surgeons The researchers surveyed … Taiwanese orthopedic surgeons and found that a national campaign encouraging surgeons to mark the incision … https://psnet.ahrq.gov/issue/patient-safety-taiwan-survey-orthopedic-surgeons

98. Identifying resilience: a system safety review of trauma and orthopaedic theatres. | PSNet
    psnet.ahrq.gov/issue/identifying-resilience-system-safety-review-trauma-and-orthopaedic-theatres
    October 19, 2011 - QI handbook) to explore how work-as-done and system resilience prevent never events in trauma and orthopedic … surgery in the UK. … View More See More About The Topic Hospitals Operating Room Surgery Orthopedic … Surgery Surgical Complications View More

99. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73873/psn-pdf
    September 29, 2021 - In August 2017, the Department of Orthopedic Surgery at Cedars Sinai Medical Center launched a web- … based, real-time complication reporting platform to encourage incident reporting among orthopedic residents

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60952/psn-pdf
     September 30, 2020 - general medicine ward and managed with antibiotics, subcutaneous insulin, and intravenous fluids and the orthopedic … First, it was not clearly stated in this Case whether an Internal Medicine team or an Orthopedics team … It would be unlikely that the orthopedics team would be managing the DKA, so it would be important to … In academic settings, orthopedic surgery residents may primarily manage many patients that do not have … complex issues; however, this patient would be better served on an internal medicine team with the orthopedics