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3561. Misconnection Leading to Arterial Thrombosis | PSNet
      psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
      January 29, 2021 - The radial artery, in particular, follows a variable course in different patients. … Approaches to Improving Patient Safety Avoid injecting drugs and air bubbles into arterial lines All … Christian Bohringer, MBBS Consulting Editor, AHRQ, Patient Safety Network (PSNet) Professor of Clinical … Safety Authority. … Tubing Misconnections: Making the Connection to Patient Safety.

3562. Ensuring Patient and Workforce Safety Culture in Healthcare | PSNet
      psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
      March 27, 2024 - In addition to specific health outcomes, patients report having better experiences with their care when … the culture of patient safety is strong. … , it can improve behaviors related to patient safety. … National Steering Committee for Patient Safety. Declaration to advance patient safety. … https://www.ihi.org/initiatives/national-steering-committee-patient-safety/declaration-advance-patient-safety

3563. An Untimely End Despite End-of-Life Care Planning | PSNet
      psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
      February 01, 2012 - Engagement of patients and families and frontline clinicians is necessary to establish a culture of safety … End of Life Care: A Patient Safety Issue. Quick Safety. July 2015;(15):1-4.  5. … Preventing harm in the ICU—building a culture of safety and engaging patients and families. … December 18, 2014 Outcomes of Michigan Medicine's integrated patient safety and communication … October 23, 2024 Trainees' perceptions of patient safety practices: recounting failures

3564. Anesthesia: A Weighty Issue | PSNet
      psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
      September 01, 2006 - If the patient could not receive a block for technical reasons, patient preference, or contraindications … satisfaction and decreased patient-controlled analgesia narcotics use.( 5 ) Finally, a patient in this … March 10, 2011 Improving safety and eliminating redundant tests: cutting costs in U.S … June 2, 2021 Using event reports in real-time to identify and mitigate patient safety … February 23, 2022 Creating a stronger culture of safety within US community pharmacies

3565. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49492/psn-pdf
      November 01, 2005 - National Patient Safety Goals for 2006 and 2005. … Available at: http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm. … OSF Healthcare’s journey in patient safety. … Effectiveness of a pharmacist-acquired medication history in promoting patient safety. … +safety/npsg.htm http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm http://www.ncbi.nlm.nih.gov

3566. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
      May 01, 2014 - Medication reconciliation during transitions of care as a patient safety strategy: a systematic review … Arch Intern Med. 2012;172:1057-1069. http://www.ncbi.nlm.nih.gov/pubmed/22733210 14 Patient Safety … Goal Medication reconciliation widely embraced as an important patient safety strategy worldwide The … National Patient Safety Goals: Hospital Accreditation Program. January 2014. … safety Future research should focus on Determining the highest risk patients Building tools which allow

3567. Safety Considerations in Building a Point-of-Care Ultrasound Program | PSNet
      psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
      June 01, 2018 - Building a POCUS program that optimizes patient safety and patient-centered outcomes requires judgment … Making Health Care Safer: A Critical Analysis of Patient Safety Practices. … These patients can go to the OR. … to the National Patient Safety Agency and recommendations for hospital practice. … November 25, 2020 Patient safety in otolaryngology: a descriptive review.

3568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33747/psn-pdf
      March 01, 2013 - safety. … The conceptual arguments for patient safety are compelling (1) and these, together with the empiric … safety concerns, and available resources. … safety through the thoughtful use of simulation. … Patient outcomes in simulation-based medical education: a systematic review.

3569. Check the Anesthesia Machine | PSNet
      psnet.ahrq.gov/web-mm/check-anesthesia-machine
      August 01, 2006 - Safety: A Personal Story August 1, 2006 WebM&M Cases … safety, teamwork, safety leadership, and simulation to healthcare leaders and managers. … August 31, 2011 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … Safety Research December 1, 2003 Critical role of the surgeon–anesthesiologist … relationship for patient safety.

3570. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
      December 01, 2011 - devices among clinicians and their common health care uses Describe the benefits of mobile technology to safety … * * Case: Multitasking Mishap (2) The patient underwent successful PEG tube replacement on hospital … rounding with the attending, the resident was able to enter orders in real time as team members evaluated patients … Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled … enhance communication, access to literature, and connectivity to clinical systems, enhancing quality, safety

3571. One Dose, Fifty Pills | PSNet
      psnet.ahrq.gov/web-mm/one-dose-fifty-pills
      January 13, 2021 - Unfortunately, pride and shame can take precedence over patient safety. … Second, system-based interventions can preserve patient safety and educate housestaff while hopefully … The answer to this seeming conflict of autonomy versus patient safety is in creating a culture where … Creation of a Medical Procedure Service to Improve Patient Safety March 1, 2008 … May 12, 2021 Establishing a multi-institutional quality and patient safety consortium

3572. Delayed Diagnosis of Endocrinologic Emergencies | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
      November 13, 2024 - The mortality rates for thyroid storm range from 10%–75% of hospitalized patients.( 1 ) Myxedema coma … presents in older women—frequently in the winter months—but it can occur in both sexes and in younger patients … amiodarone-induced thyrotoxicosis or amiodarone-induced hypothyroidism may develop in 14% to 18% of all patients … safety: systematic review and meta-analysis. … transfusion safety.

3573. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867672/psn-pdf
      February 26, 2025 - with severe abdominal pain and in patients with peritoneal tenderness. … Case Analysis This case involved a patient presenting with high-risk abdominal pain. … Safety Imaging in High-Risk Abdominal Pain Patients presenting to the ED with abdominal pain of uncertain … Safety Network (PSNet) Professor Department of Surgery, Division of Trauma, Acute Care Surgery, and … Barnes, MD, FACEP Consulting Editor, AHRQ’s Patient Safety Network (PSNet) https://psnet.ahrq.gov//

3574. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49479/psn-pdf
      April 01, 2005 - Three days later, a physician evaluated the patient and reviewed her progress. … Four days later, the patient became unresponsive. … failure to recognize discordant orders, this case presents an opportunity to systematically improve safety … CPOE is undoubtedly among our most powerful tools to enhance patient safety, but its optimal implementation … Computerized provider order entry (CPOE) is a powerful tool to address a range of patient safety issues

3575. Missed Pneumonia | PSNet
      psnet.ahrq.gov/web-mm/missed-pneumonia
      June 01, 2005 - The patient had taken a 2-hour plane ride the day before onset of symptoms. … The patient quickly improved on antibiotics and was discharged 2 days later. … Does this patient have community-acquired pneumonia? … April 12, 2023 Development of patient safety measures to identify inappropriate diagnosis … Perspective The Role of Bar Coding and Smart Pumps in Safety

3576. In Conversation with...Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
      October 01, 2010 - safety. … large academic medical center, focused on patient safety. … So if the nurses see them not doing something that they should be doing for patient safety, then they … I think patients deserve better than that. … University of Calgary, Canadian Patient Safety Institute, Calgary, Canada; 2009.

3577. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865376/psn-pdf
      March 27, 2024 - The Commentary By Caitlin Loseth, MD The management of severely injured patients requires complex … Patients with cirrhosis exist in a delicate physiologic homeostasis where https://psnet.ahrq.gov//#4 … There was no mention of abdominal wall varices, but this is a common pitfall in operating on patients … When such patients are hypotensive at presentation, and progress to require CPR in the field or in the … CPR often needs to be paused in the setting of acute ATLS procedures in order to ensure safety.

3578. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet
      psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
      October 27, 2021 - This case highlights the importance of communication between team members to improve patient safety. … Available at: https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery … Available at: https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/ … September 9, 2020 Analysis of patient safety risk management call data during the COVID … 2025 Patient Safety Primers Wrong-Site, Wrong-Procedure

3579. Right Electrocardiogram, Wrong Patient | PSNet
      psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
      April 24, 2024 - The incorrect patient documentation on the EKG caused EKG results to be uploaded to the wrong patients … private health analytics firm, which has logged over 15,000 electronic health record (EHR) related safety … Fortunately, there were no adverse effects on any of the patients involved in the cases of mentioned … Effect of Bar-Code Technology on the Safety of Medication Administration. … September 27, 2023 Patient Safety Innovations Remote

3580. Primary Workaround, Secondary Complication | PSNet
      psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
      January 24, 2018 - However, hospital safety leaders realized that this practice was common for hospitalized patients as … well, potentially putting many patients at risk. … Communication about the use of workarounds is essential for patient safety. … To Do No Harm: Ensuring Patient Safety in Health Care Organizations. Jossey-Bass; 2005. … safety culture and patient experience in hospital settings: a scoping review.