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Showing results for "risks".

8421. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
      psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
      December 14, 2022 - manifesting with benign skin hamartomas, pulmonary cysts and spontaneous pneumothorax, and an increased risk … study, the rate of recurrence decreased from more than 60% to 27% after pleurodesis. 7   Given the risk … These patients have a high risk of recurrence of spontaneous pneumothorax, and referral to a lung center … , 2022 WebM&M Cases The Lost Start Date: an Unknown Risk … WebM&M Cases Multiple Missed Opportunities for Suicide Risk

8422. Failure to Latch | PSNet
      psnet.ahrq.gov/web-mm/failure-latch
      November 27, 2012 - Under certain circumstances, though, hyperbilirubinemia can become severe and place newborns at risk … 2006, the AAP published revised guidelines for managing hyperbilirubinemia in newborns by calling for risk … of breastfeeding is overwhelming.( 14 ) Breastfeeding enhances maternal-infant bonding, diminishes risk … Infants who are not breastfed also have a higher risk of developing obesity and diabetes. … The value is plotted on a nomogram by hour of life to determine the risk of severe hyperbilirubinemia

8423. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
      January 01, 2024 - MISSED CONNECTION: A CASE OF INADEQUATE ECG OVERSIGHT IN CARDIAC SURGERY A case highlighting the risks … internal paddles delivering the electric shock should be applied directly to the atria to minimize the risk … Teaching defibrillators” are now available that reduce the cost of training equipment and eliminate the risk … Synchronized shocks and pacing should be used whenever possible to reduce this risk. … Hidden risk in operating room. Micro-shock.

8424. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41631/psn-pdf
      September 24, 2016 - interruptions-and-multitasking-nursing-care https://psnet.ahrq.gov/issue/association-interruptions-increased-risk-and-severity-medication-administration-errors

8425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39787/psn-pdf
      August 25, 2010 - national-estimates-adverse-events-during-nonpsychiatric-hospitalizations- persons Patients with schizophrenia are at greater risk

8426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41593/psn-pdf
      August 15, 2012 - facility-level-variation-potentially-inappropriate-prescribing-older-veterans https://psnet.ahrq.gov/issue/potentially-inappropriate-medications-defined-stopp-criteria-and-risk-adverse-drug-events

8427. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39688/psn-pdf
      July 14, 2010 - reveals insights on reliability, reporting, and system improvement gleaned from his career in high-risk

8428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60042/psn-pdf
      March 11, 2020 - perspective/safety-retail-pharmacy https://psnet.ahrq.gov/issue/how-chaos-chain-pharmacies-putting-patients-risk

8429. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43748/psn-pdf
      December 03, 2014 - psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance https://psnet.ahrq.gov/issue/managing-risk-during-transition-new-iso-tubing-connector-standards

8430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37564/psn-pdf
      June 12, 2008 - than medical patients stimulated medical emergency team activity, suggesting opportunities to further risk

8431. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43451/psn-pdf
      August 20, 2014 - J Healthc Risk Manag. 2014;34(1):6-12. doi:10.1002/jhrm.21145.

8432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45054/psn-pdf
      May 18, 2016 - https://psnet.ahrq.gov/issue/double-checking-second-look Manual double checking of high-risk medication

8433. Learning from Errors: Analysis of a Medication Error | PSNet
      psnet.ahrq.gov/training-catalog/learning-errors-analysis-medication-error
      one-hour session from NTI 2023 uses a case study approach to  analyze medication error events and discuss risk-mitigation

8434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42090/psn-pdf
      March 06, 2013 - adverse-drug-events-paediatric-intensive-care-unit-prospective-cohort This study used trigger tools to identify the incidence and risk

8435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39376/psn-pdf
      March 17, 2010 - evaluation-inpatient-admissions-and-potential-antimicrobial-and-analgesic- dosing-errors Overweight children were at a significantly increased risk

8436. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41297/psn-pdf
      September 19, 2012 - commentary explores the benefits and drawbacks of using failure mode and effects analysis as a prospective risk

8437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851927/psn-pdf
      August 02, 2023 - issue/perioperative-handoffs Handoffs occur several times during a surgical procedure, increasing the risk

8438. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44503/psn-pdf
      November 18, 2024 - safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk

8439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40569/psn-pdf
      June 29, 2011 - inappropriate-medications-elderly-icu-survivors-where-intervene https://psnet.ahrq.gov/issue/potentially-inappropriate-medications-defined-stopp-criteria-and-risk-adverse-drug-events

8440. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74095/psn-pdf
      February 01, 2022 - https://psnet.ahrq.gov/primer/never-events https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment