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Total Results: 1,558 records

Showing results for "small".

421. Barcode technology flaws put some patients at risk. | PSNet
     psnet.ahrq.gov/issue/barcode-technology-flaws-put-some-patients-risk
     July 23, 2008 - August 31, 2016 Small patients, big consequences in medical errors.

422. Are hospitals in a med safety standard slump? | PSNet
     psnet.ahrq.gov/issue/are-hospitals-med-safety-standard-slump
     November 21, 2018 - October 24, 2018 Preventing medication errors at small and rural hospitals.

423. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
     January 01, 2023 - with abdominal distension, tachycardia and quick progression to septic shock, a gastric or proximal small … – The stomach and proximal small bowel contain erosive and acidic contents that can lead to more … mortality.18 • In other cohorts, the presence of sepsis was a negative prognostic factor for both small … Predictors of mortality in patients with acute small-bowel perforation transferred to ICU after emergency

424. Robotic Surgery: Risks vs. Rewards | PSNet
     psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
     October 31, 2023 - The robotic surgery, he explained, would involve a few small incisions, performed by a surgeon seated … Like traditional laparoscopy, RAS uses small incisions and insufflation of the anatomical operative space … There is a small risk of temporary, and even permanent, nerve palsies from the extreme body positioning … December 2, 2020 WebM&M Cases Nothing Called Small Surgery

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49662/psn-pdf
     August 01, 2012 - into the colon, which meant that the feedings were bypassing the entire digestive apparatus of the small … Once the safe track is confirmed, a trocar is inserted through a small abdominal skin incision into the … PEG insertion site, hemorrhage, peritonitis, buried bumper syndrome, gastrocolocutaneous fistula, small

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49864/psn-pdf
     June 01, 2019 - The physician scanned the patient and noted a small effusion on the right side. … He then called the medicine team and mentioned that he found a very small effusion on the right side … Creating a cultural norm of speaking up is no small feat as there are many disincentives to do so, especially

427. Inadequate Preanesthetic Evaluation, Airway Trouble | PSNet
     psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
     November 01, 2023 - laryngoscopy and intubation proved extremely difficult as the posterior tongue mass, the size of a small … Long upper incisors, protuberant teeth Prominent overbite Inability to protrude mandible Small … mouth opening Large tongue or small pharynx Mallampati classification III or IV High, arched palate

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33826/psn-pdf
     February 01, 2017 - wrong, it's often a system breakdown, not individual human error or negligence, but rather a series of small … looking for whom to blame and to start thinking and working together to redesign the system or make small … And small changes can make a big difference. … So this was an example of a small intervention that made a substantial difference.

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33787/psn-pdf
     January 01, 2018 - default.aspx http://dx.doi.org/10.1377/hlthaff.27.3.759 RW: When you started at IHI, the organization was small … and the worlds of safety and quality were also small. … Every 90 days we convene small teams of people who take on intractable problems in health care. … Don Berwick and a small number of experts from around the world recently served on a commission in England

430. When a vital sign leads a country astray—the opioid epidemic. | PSNet
     psnet.ahrq.gov/issue/when-vital-sign-leads-country-astray-opioid-epidemic
     May 27, 2020 - 27, 2020 Doctors can change opioid prescribing habits, but progress comes in small

431. The Human Factors Analysis Classification System (HFACS) applied to health care. | PSNet
     psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care
     November 16, 2022 - September 12, 2016 Deaths due to medical error: jumbo jets or just small propeller planes

432. Your high-alert medication list—relatively useless without associated risk-reduction strategies. | PSNet
     psnet.ahrq.gov/issue/your-high-alert-medication-list-relatively-useless-without-associated-risk-reduction
     May 07, 2014 - June 26, 2013 Small effort, big payoff...automated maximum dose alerts with hard stops

433. Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. | PSNet
     psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-leading-drug
     June 10, 2018 - October 17, 2018 Small effort, big payoff...automated maximum dose alerts with hard stops

434. Themed Issue on the Opioid Epidemic. | PSNet
     psnet.ahrq.gov/issue/themed-issue-opioid-epidemic
     January 14, 2019 - September 2, 2020 Doctors can change opioid prescribing habits, but progress comes in small

435. Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. | PSNet
     psnet.ahrq.gov/issue/hospital-bed-system-dimensional-and-assessment-guidance-reduce-entrapment
     October 28, 2010 - October 28, 2010 Safety considerations to mitigate the risks of misconnections with small-bore

436. Medical Errors and Patient Safety: A Curriculum Guide for Teaching Medical Students and Family Practice Residents. | PSNet
     psnet.ahrq.gov/issue/medical-errors-and-patient-safety-curriculum-guide-teaching-medical-students-and-family
     September 16, 2015 - February 9, 2011 Small patients, big consequences in medical errors.

437. Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data. | PSNet
     psnet.ahrq.gov/issue/scanning-out-medication-errors-ohio-valley-hospitals-automated-iv-system-provides-real-time
     December 21, 2016 - and Improve Health Outcomes March 29, 2023 Preventing medication errors at small

438. Fail-safe patient ID matching remains just out of reach. | PSNet
     psnet.ahrq.gov/issue/fail-safe-patient-id-matching-remains-just-out-reach
     October 05, 2016 - July 11, 2018 Small effort, big payoff...automated maximum dose alerts with hard stops

439. Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg. | PSNet
     psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-and-mg
     June 10, 2018 - September 20, 2017 Small effort, big payoff...automated maximum dose alerts with hard

440. Should we disclose harmful medical errors to patients? If so, how?   | PSNet
     psnet.ahrq.gov/issue/should-we-disclose-harmful-medical-errors-patients-if-so-how
     November 23, 2016 - August 10, 2022 Doctors can change opioid prescribing habits, but progress comes in small