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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - procedures to
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
guide management of the insulin pump patient during hospitalization … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#box
https://psnet.ahrq.gov//#references … Professor of Medicine
Division of Endocrinology Mayo Clinic, Scottsdale, AZ
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
References
1.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - regimens
Discontinuity of care
Short hospitalizations
Inadequate patient education
See Notes for references … discharge
Cause half of all preventable adverse drug events 30 days after discharge
See Notes for references … responsibilities for each component of the process assigned to the parties involved
See Notes for references … in continuous improvement and monitoring for compliance are likely success factors
See Notes for references … staff should ensure that patients are educated about any changes in medication regimen
See Notes for references
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - Autonomy and physician (not just housestaff) independence have long
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
histories in western medicine.(5,6) Physicians have consistently … preserve patient safety and educate housestaff while hopefully preserving
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
a sense of physician autonomy.
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psnet.ahrq.gov/node/49468/psn-pdf
December 16, 2004 - conclusion, all of the surgical,
https://psnet.ahrq.gov/web-mm/mark-my-limb
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
anesthesia and nursing professionals … https://psnet.ahrq.gov//#references
Today, the Universal Protocol and the specific internal systems … Healthcare Organizations Emeritus Professor of Family Medicine, University of Minnesota Medical School
References
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
Unfortunately, that did not help the clinicians determine if the … University Neuropsychiatric Institute South Jordan Health Center Clinical
Laboratories Salt Lake City, UT
References … [go to PubMed]
https://psnet.ahrq.gov//#table
https://psnet.ahrq.gov//#references
https://www.ncbi.nlm.nih.gov
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - personal safety
Also leads to safety risks due to the decreased capacity of the patient
See Notes for references … police by security as appropriate
Notification of appropriate administrative personnel
See Notes for references … to unit
May depend on time elapsed
Providers should be familiar with local policies
See Notes for references … adequately supervise and observe patients and to maintain safe conditions on the premises
See Notes for references … patient’s condition
Failure to properly search for the patient following elopement
See Notes for references
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Sinusitis occurs after or in
conjunction with a viral upper
respiratory tract infection
See Notes for references … guidelines from both CDC and American Academy of Otolaryngology–Head and Neck Surgery
See Notes for references … infections, including
sinusitis, since these infections
are rarely bacterial in origin
See Notes for references … prescribing possibly counteracted by increase in prescribing broad-spectrum antibiotics
See Notes for references … criteria
Desire to respond to patient’s explicit
(or implied) request for antibiotics
See Notes for references
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psnet.ahrq.gov/node/49487/psn-pdf
August 21, 2005 - investigators and teachers to independently develop and sustain the web-based
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#slideshow
infrastructure for every quality … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#figure … https://psnet.ahrq.gov//#references
Jeffrey M. … for Research &
Innovation in Patient Care University of California, San Francisco School of Nursing
References
-
psnet.ahrq.gov/node/49391/psn-pdf
February 01, 2003 - https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#table … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references … What systems can do:
https://psnet.ahrq.gov//#references
Use “M&M” conferences to highlight the “myth … , MD, MS Department of Psychiatry, Brown University Rhode Island Hospital and The
Miriam Hospital
References
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psnet.ahrq.gov/node/49644/psn-pdf
December 01, 2011 - https://psnet.ahrq.gov/web-mm/missing-point-eye-injury
https://psnet.ahrq.gov//#references
The ED assessment … and both globe and intracranial injury are
https://psnet.ahrq.gov//#figure
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
Rahul Sharma, MD, MBA Assistant Director for Operations Department … Clinical Affairs Associate
Professor, Department of Emergency Medicine University of Minnesota
References
-
psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - The residents and staff perhaps subconsciously attempted to correlate their
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
examination findings with what they expected to observe. … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#figure
based on conversations with recent … https://psnet.ahrq.gov//#references
References
1. Cook DJ.
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psnet.ahrq.gov/node/49780/psn-pdf
January 01, 2017 - https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Twenty-five years later, PACS … possible displayed, in the OR during surgery in addition to reviewing the
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
images prior to surgery. … References
1. Clarke-Pearson DL, Geller EJ. Complications of hysterectomy.
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - REFERENCES
28
References
29
1. Kelly KJ, Sussman G. … pubmed/2005317
https://www.ncbi.nlm.nih.gov/pubmed/8027499
http://www.ncbi.nlm.nih.gov/pubmed/12006967
References … Occup Environ Med. 54:335-342 1997
PMID: 9196456
References
31
30.Lagier F, Vervloet D, Lhermet … Closure (2)
Latex Allergy Loop Closure (3)
Take home points
Latex Allergy Take Home Points (1)
References … References
References
References
-
psnet.ahrq.gov/node/49862/psn-pdf
May 01, 2019 - Today ferromagnetic detectors also have been
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov … //#references
https://psnet.ahrq.gov//#references
developed that can specifically scan and screen for … Director, Magnetic Resonance Services
Professor of Radiology and Neuroradiology
https://psnet.ahrq.gov//#references … Department of Radiology
University of Pittsburgh Medical Center
References
1.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - States will be transferred to a different ICU
Up to 90% of transfers can be non-emergent
See Notes for references … rate remains low, up to 17% of these adverse events result in potential harm to patients
See Notes for references … another study, 42% of calls between facilities had errors of either commission or omission
See Notes for references … Inappropriate transport method
Inappropriate personnel accompanying the patient
See Notes for references … shown to improve communication, efficiency, and appropriateness of transport services
See Notes for references
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
An extensive body of literature … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
How could the errors in this … Marlene Miller, MD, MSc Vice Chair, Quality and Safety
https://psnet.ahrq.gov//#references
https:// … psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Johns Hopkins Children's Center
Baltimore … References
1. Santell JP, Hicks R. Medication errors involving pediatric patients.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - interruptions during drug retrieval by creating a zone of safety around medication storage
See Notes for references … Individual feelings of helplessness, fear, and anxiety
Avoidance of guilty feelings
See Notes for references … learning opportunity for staff and a chance to evaluate the system for improvements
See Notes for references … report for this event allowing learning opportunity to be expanded to entire organization
See Notes for references … Success attributed to non-punitive culture and assurance of reporter confidentiality
See Notes for references
-
psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - order of decreasing frequency,
https://psnet.ahrq.gov/web-mm/listen-family
https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
were eye, groin or genitals … https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#figure … King Ransom Professor of Surgery Chief of Clinical Affairs University of
Michigan Health Systems
References
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
February 01, 2011 - for more experienced physicians, who may be overly confident in their knowledge base
*
See Notes for references … assessment is a complex task that requires time, skill, and often guidance from others
*
See Notes for references … imperative: seek external guidance and input when practice outside defined or usual scope
*
See Notes for references … competence
Challenge: improved methods for ongoing practice based assessment and learning
*
See Notes for references … methods for self assessment
Alignment with future changes in maintenance of licensure
*
See Notes for references
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - advocates “competent care”—to avoid judgment distinction between competence and excellence
See Notes for references … require a “systems” prevention approach as patients at high risk can be identified
See Notes for references … patients adds obstacles to determining ethical standards and decision-making capacity
See Notes for references … because they have higher risk of mental health disorders and subtle cognitive deficits
See Notes for references … collaborating with a shelter worker, priest, or a homeless person that patient looks up to
See Notes for references