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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Objectives
At the conclusion of this educational activity, participants should be able to:
Describe the risk … Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
A case highlighting the risk factors … caring for patients with a tracheostomy:
Premature transfer to a lower level of care during a high-risk … care, acute care hospitals must assess the ability of the accepting facility and the patient-specific risk … Clinicians should also assess the patients with tracheostomies who may be at increased risk for greater
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - A Bayesian approach is needed: widespread use of CT in low-risk patients will lead to significant numbers … Transitions of care are high-risk points for error, allowing insertion of “pseudo-information,” and enabling … Appendiceal perforation increases the risk of wound infection, abscess formation, sepsis, wound dehiscence … In women, there is a five-fold increased risk of infertility.( 2,13 )
In lieu of a guideline to ensure … Appendectomy and the risk of tubal infertility.
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psnet.ahrq.gov/node/40919/psn-pdf
November 16, 2011 - preventing-infections-during-cancer-treatment
This Web site provides resources for patients and practitioners to help reduce risk
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psnet.ahrq.gov/node/36317/psn-pdf
October 11, 2006 - Int J Risk Safety Med. 2006;18(3):181-186.
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psnet.ahrq.gov/node/37203/psn-pdf
July 05, 2019 - and a toolkit regarding standardizing the colors of wristbands, stickers, and
placards to signify risk
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - Finally, in the effort to maximize use of telehealth services and minimize the risk of patient exposure … However, there are critical precautions that can be taken to minimize the risk to patient safety. … We knew we were going to have issues with an unknown “hot zone” in the ED where the risk of transmission … The goal at our clinic, like that of many all over the country I’m sure, is to lower exposure risk by
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psnet.ahrq.gov/node/33883/psn-pdf
July 01, 2019 - they're taking advantage of the electronic health record (EHR) to implement systems for
detecting at-risk … your sense of how AI is doing in radiology, dermatology, pathology, and fields like that, and
what risks … So scanning retinal images to identify risk
of diabetic retinopathy is a good example where people are … It has to be a combination of rigorously validated careful risk analysis and deep
understanding of what's
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model … Then the idea was to have a subset of doctors who focused their practice only on patients at high risk … of hospitalization than with people who are at lower risk. … The only difference is you've reallocated the high-risk patients to one doctor.
RW : Got it. … I would try to figure out what strategies you have available to either identify patients at high risk
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - Then the idea was to have a subset of doctors who focused their practice only on patients at high risk … of hospitalization than with people who are at lower risk. … But the truth is that if you're not at very high risk of hospitalization, the model is not more costly … The only difference is you've reallocated the high-risk patients to one doctor.
RW : Got it. … I would try to figure out what strategies you have available to either identify patients at high risk
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - costs, increases the opportunity for diagnostic errors.( 23 ) Under-resourced EDs are a significant risk … Similarly, the use of treatment protocols or algorithms may reduce the risk of error.( 12 ) Ensuring … Body mass index, abdominal fatness and the risk of gallbladder disease. … Hoffman J, Yu W. 2011 Annual Benchmarking Report: Malpractice Risks in Emergency Medicine. … Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis.
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Colonization of the nares either before hospitalization or following admission puts patients at increased risk … and
those with chronic skin conditions.(11) In addition, prior antibiotic exposure is an important risk … One study indicated that the
patients with MRSA in their blood had a risk of dying twice that of patients … there is considerable evidence
to support the use of active surveillance cultures for identifying high-risk … If rates of MRSA become publicly reported, some hospitals
may avoid caring for high-risk patients, impacting
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - World Health Organization (WHO) and The Joint Commission have
recommended strategies for reducing the risk … Safety: Building Safer
Systems for Better Care, which expressed deep concerns about the public health risk … Although the report noted that there is little published
evidence quantifying the magnitude of the risk … experts fear that EMRs that allow multiple patient records open at once are hazardous and increase the
risk … Risk models to improve safety of
dispensing high-alert medications in community pharmacies.
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psnet.ahrq.gov/node/50391/psn-pdf
September 25, 2019 - and peritonitis (rigidity, guarding, rebound).5 Clinicians who are not mindful of the prevalence and risk … cholecystectomy, and surgery should occur during the index
hospitalization unless the patient is a prohibitive risk … Moreover, delay in surgery for greater
than 48 hours is associated with longer length of stay, higher risk … of conversion to an open procedure,
greater complication risk, and increased cost.11-13 Therefore, … Patients at high risk for surgery may be offered percutaneous gallbladder
drainage instead.
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - medical errors with an underlying assumption of full disclosure, but work closely with experienced risk … managers throughout the disclosure process to minimize unanticipated legal risks. … desire to discuss the circumstances of the error and their feelings with a trusted colleague, many risk … Physicians should seek help from institutional risk managers or others skilled in disclosure before discussing
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - transfer error.( 3 ) Handoffs in surgical care often involve equipment transfers, which may carry higher risk … remain undetected for significant periods of time—as illustrated by this case—further compounds this risk … substantial part of human work involves making tradeoffs, for example, between safety and efficiency or risk … FMEA) of process
Safety checks built into process
Prediction of future patient needs and likely risks
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - medical
errors with an underlying assumption of full disclosure, but work closely with experienced risk … managers
throughout the disclosure process to minimize unanticipated legal risks. … desire to discuss the circumstances of the error and their
feelings with a trusted colleague, many risk … Physicians should seek help from institutional risk managers or others skilled in disclosure before
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - than identifying
simple relationships—redundancy and codependency abound.(1,2) The dependencies among risk … times to diagnose and have markedly different
probabilities of occurrence, and each has different risks … Do diagnostic plans incorporate the risk/benefit of finding one
diagnosis rather than another? … Effectiveness of a multidisciplinary chest pain unit for the
assessment of coronary syndromes and risk
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Another answer is that when there are risk factors for "atypical"
causes, such as the patient being … daily dose were to be continued for more
than a month, this postmenopausal woman would be at a high risk … Postmenopausal women, especially those with other risk factors for osteoporosis.
… frequently, intravenously, will often suppress the disease flare
and spare the patient the long-term risks
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psnet.ahrq.gov/node/40243/psn-pdf
June 10, 2018 - preventing-medication-errors-during-codes
This piece discusses medication errors during emergency resuscitations and outlines risk-reduction
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psnet.ahrq.gov/node/36336/psn-pdf
October 26, 2010 - that explore successful multidisciplinary efforts to improve patient safety,
including medication risk