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psnet.ahrq.gov/issue/remote-video-auditing-real-time-feedback-academic-surgical-suite-improves-safety-and
August 04, 2021 - Root cause analysis and actions for the prevention of medical errors: quality improvement and resident
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psnet.ahrq.gov/issue/systematic-review-effectiveness-interruptive-medication-prescribing-alerts-hospital-cpoe
August 17, 2016 - ventilation incidents in the community
January 22, 2020
Sustained impact of a pediatric resident-led
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psnet.ahrq.gov/issue/variations-gps-decisions-investigate-suspected-lung-cancer-factorial-experiment-using
August 03, 2022 - reporting of clinically significant events—a novel way to improve handoff communication and supervision of resident
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psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
June 02, 2021 - Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - The same note was then copied and pasted on 4 consecutive hospital days and cosigned by the resident … Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident
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psnet.ahrq.gov/web-mm/security-lapse
December 18, 2019 - that a consultant would be less willing to help in the future, dread of public mockery from a senior resident … For example, a student can report to the resident, or to an attending physician.
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - In the preoperative treatment area, the Anesthesiology resident flushed
the IV cannula to ensure that … in other inpatient settings.3
Systems Change Needed/Quality Improvement Approach
At a minimum, the resident
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Once in the operating room, the resident placed an arterial line in the
patient's left arm under local … The logbook on the anesthesia machine
showed that the machine had been checked that morning, but the resident
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - January 25, 2023
A systematic review of the effects of resident duty hour restrictions … in surgery: impact on resident wellness, training, and patient outcomes.
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psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa
June 29, 2023 - October 21, 2015
Elucidating reasons for resident underutilization of electronic adverse
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psnet.ahrq.gov/issue/safety-manchester-triage-system-detect-critically-ill-children-emergency-department
October 18, 2023 - May 8, 2017
The effects of resident level of training on the rate of pediatric prescription
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - May 18, 2022
Improving resident handoffs for children transitioning from the intensive
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psnet.ahrq.gov/issue/single-room-hospital-accommodation-associated-differences-healthcare-associated-infection
June 21, 2016 - December 8, 2021
Rates of adverse events in hospitalized patients after summer-time resident
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psnet.ahrq.gov/issue/do-variations-hospital-mortality-patterns-after-weekend-admission-reflect-reduced-quality
April 12, 2019 - February 9, 2012
Improving the discharge process by embedding a discharge facilitator in a resident
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - The gynecologist had received an incomplete report on the first ultrasound’s findings from a resident … The resident and the patient did not mention her history of a bicornuate uterus.
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - patient's lower than normal initial Scr value of 0.4 mg/dL from the outside hospital, the admitting resident … Had it been recognized, the admitting resident would have been prompted to reevaluate vancomycin dose
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - In the step-down unit, the resident wrote an order for a maintenance dose of phenytoin. … Later that day, a pharmacist called to alert the resident to his mistake.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Case: Resuscitation Errors
The cardiology resident arrived and confirmed torsades on the monitor. … The patient remained in torsades until the resident administered magnesium, which resulted in rapid conversion
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - In this anachronistic model, the non-surgeon
physician, resident, nurse, and technician team members … Forrest Calland, MD Resident in Surgery Research Fellow and Co-Founder, Surgical Technology and
Safety
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - Had the resident seen a picture of Mr. B instead of Mr. … completed within the electronic record,
additional safety guards could be used, such as verifying the resident