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psnet.ahrq.gov/node/35813/psn-pdf
April 06, 2011 - April 6, 2011
Shapiro MJ, Morey JC, Small SD, et al.
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psnet.ahrq.gov/node/35324/psn-pdf
February 03, 2011 - Despite the small sample size, the authors conclude that training programs may need to consider various
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psnet.ahrq.gov/node/37701/psn-pdf
February 22, 2011 - ubiquitous, but are limited by low clinician reporting rates and the fact that
they identify a relatively small
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psnet.ahrq.gov/node/33747/psn-pdf
March 01, 2013 - simulation is non-inferior to other approaches.(
3,4) Technology-enhanced simulation is associated with a small … Finally, selecting the simulator is only a small step in the development of simulation-based education … Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative.
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - But my father was a horse-and-buggy GP [general practitioner] in a small Connecticut town, and I knew … But small farming town kid, that's me. … One is small town roots—you grew up in a city, Bob?
RW: I grew up in the suburbs, Long Island. … It's as if the small community part is there. A second is, I really love doctoring. … But the business plan of the Institute is to remain very small.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.92_slideshow.ppt
April 01, 2005 - An abdominal x-ray revealed a pattern consistent with a partial small bowel obstruction. … Her small bowel obstruction continued to improve and no surgical intervention was necessary. … Prevention of Contrast Nephropathy
Avoid contrast
Use ultrasound, MRI
Use small amounts of contrast
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psnet.ahrq.gov/issue/use-barcode-scanning-prevent-errors-enteral-nutrition-feedings
December 04, 2024 - February 1, 2023
Preventing medication errors at small and rural hospitals.
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psnet.ahrq.gov/node/43027/psn-pdf
July 23, 2014 - Only a small proportion of
unique information shared with nurses and technicians was learned by the
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psnet.ahrq.gov/node/34792/psn-pdf
January 01, 2011 - Food and Drug
Administration’s reporting system, and a very small percentage actually had reported an
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psnet.ahrq.gov/node/42149/psn-pdf
December 23, 2016 - Because the database relies on voluntary reporting, this
number likely represents a small proportion
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psnet.ahrq.gov/node/36962/psn-pdf
June 15, 2011 - This
pattern likely influenced the spectrum of problems reported; only a small proportion of reported
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psnet.ahrq.gov/node/44575/psn-pdf
January 22, 2016 - Patient safety may have improved, but, if so, the effects were small.
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psnet.ahrq.gov/node/36291/psn-pdf
October 25, 2010 - The analysis revealed that adverse events account for a small but significant proportion of
overall
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psnet.ahrq.gov/node/42011/psn-pdf
March 06, 2013 - psnet.ahrq.gov/primer/culture-safety
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - constantly looking at every process that they're engaged in as part of their daily work to be sensitive for small … deviations—small signals that the process isn't quite working right, that the safety protocol doesn't … They find these unsafe conditions when the problems are very small—way upstream from posing serious risk … scrutinize their environment and their processes so they recognize problems when they're very, very small … MC : Hospitals and systems, a small but growing number, that have taken this challenge for high reliability
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psnet.ahrq.gov/issue/extra-dose-safety
June 16, 2019 - May 11, 2014
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals:
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - A Gastrografin (diatrizoate meglumine/ditrizoate sodium) esophagram demonstrated a small outpouching … Although EGD is a less sensitive test than esophagography (especially for small lesions), intraoperative … September 25, 2024
WebM&M Cases
Misdiagnosis of Small
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - Based on the exam and initial imaging, there was concern for small bowel
obstruction. … The hospital's case review committee felt the patient likely had severe acute pancreatitis and not a small … numbers of emergency surgeries performed and allowed greater use of non-operative
treatment in cases of small … Differentiating between,
in this case, pancreatitis and small bowel obstruction due to another cause
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - imaging showed enlarged abdominal lymph nodes as well as jejunal thickening and dilated ileum in the small … A lymph node biopsy and partial small bowel resection was undertaken. … Lymph node pathology was reported as "Castleman disease, of hyaline vascular type," while the small bowel … review reported reactive lymph nodes with hyalinization but no other features of Castleman, and normal small
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psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - Pennsylvania, and the Mayo Clinic have shown that automatic referral of high-risk kidney patients for small-bore … inappropriate PICCs.( 14-16 ) This approach requires planning to ensure the availability of resources to place small-bore … High-risk kidney patients should receive small-bore central venous catheters rather than peripherally … Evaluating safety of tunneled small bore central venous catheters in chronic kidney disease population