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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Two randomized controlled trials
evaluated whether elective open surgical repair of small AAAs improves … Immediate repair compared with surveillance of small abdominal aortic
aneurysms. … The UK Small Aneurysm Trial Participant. … Comparison of
surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from … Endovascular repair compared with surveillance for patients
with small abdominal aortic aneurysms.
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psnet.ahrq.gov/node/40537/psn-pdf
June 15, 2011 - rural-nurses-safeguarding-work-reembodying-patient-safety
https://psnet.ahrq.gov/issue/prioritizing-patient-safety-interventions-small-and-rural-hospitals … https://psnet.ahrq.gov/issue/prioritizing-patient-safety-interventions-small-and-rural-hospitals
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psnet.ahrq.gov/issue/pharmacist-staffing-technology-use-and-implementation-medication-safety-practices-rural
September 27, 2010 - The investigators surveyed small rural hospitals in the United States about safe medication practices … Related Resources From the Same Author(s)
Prioritizing patient safety interventions in small
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psnet.ahrq.gov/issue/agenda-research-ambulatory-patient-safety
December 22, 2008 - Hammons T; Piland NF; Small SD; Hatlie MJ; Burstin HR; Medical Group Management Association; MGMA
Copy … Twitter
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May 27, 2015
Hammons T; Piland NF; Small … Hammons T; Piland NF; Small SD; Hatlie MJ; Burstin HR; Medical Group Management Association; MGMA
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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - Two randomized controlled trials evaluated whether elective open surgical repair of small AAAs improves … Immediate repair compared with surveillance of small abdominal aortic aneurysms. … The UK Small Aneurysm Trial Participant. … Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from … Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms.
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - The catheters are widely available in sizes as small as 1.2 F, facilitating insertion in micropremies … When using PICCs in neonates, the
small size of the line (1.9 F [0.64 mm] in this case) can make it … Another factor was
the use of a small syringe for flushing. … It seems prudent to avoid flushing catheters under high pressure
or using small syringes. … In addition, caregivers
should be warned against flushing with small-volume syringes.(9)
Take-Home
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psnet.ahrq.gov/issue/use-unsolicited-patient-observations-identify-surgeons-increased-risk-postoperative
July 10, 2019 - Prior studies have shown that a small proportion of physicians account for a disproportionate share of … Although the absolute increase in complication rates was relatively small across all surgeons, surgeons
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psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures
October 07, 2013 - describes how a pediatric cardiac surgery team used the human factors approach of recording even small … The authors describe how systematically capturing small failures led to recognition of faulty processes
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psnet.ahrq.gov/issue/ambulatory-patient-safety-what-we-know-and-need-know
May 27, 2015 - Citation Text:
Hammons T, Piland NF, Small SD, et al. Ambulatory Patient Safety. … Twitter
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December 22, 2008
Hammons T, Piland NF, Small … URL
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Citation Text:
Hammons T, Piland NF, Small
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psnet.ahrq.gov/issue/teaching-hospital-financial-status-and-patient-outcomes-following-acgme-duty-hour-reform
November 26, 2014 - Citation Text:
Navathe AS, Silber JH, Small DS, et al. … Twitter
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April 17, 2013
Navathe AS, Silber JH, Small … Cite
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Citation Text:
Navathe AS, Silber JH, Small
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psnet.ahrq.gov/node/43809/psn-pdf
February 25, 2015 - study describes how a pediatric cardiac surgery team used the human factors approach
of recording even small … The
authors describe how systematically capturing small failures led to recognition of faulty processes
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
April 01, 2009 - removed
May be particularly challenging in neonates, as in this case
Why The Fracture in This Case
Small … Likely develop fibrin binding of catheter to vessel wall, increasing chance of breakage on removal
Small … on catheter
*
Recommendations for Prevention
Avoid flushing PICCs under high pressure or with small … insertion site) are associated with PICC fractures
Caregivers should be warned against flushing PICCs with small-volume
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. … Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. … https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures … it has universality in both
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small … Instead, new behaviors (and concomitant attitudes and cultural norms) are born and grow
through small
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psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
July 22, 2020 - The investigators found that errors occurred at each stage of the process, with a small but significant … September 29, 2010
Safety on an inpatient pediatric otolaryngology service: many small
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psnet.ahrq.gov/issue/simulation-based-teamwork-training-emergency-department-staff-does-it-improve-clinical-team
December 22, 2009 - Citation Text:
Shapiro MJ, Morey JC, Small SD, et al. … Twitter
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April 6, 2011
Shapiro MJ, Morey JC, Small … URL
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Citation Text:
Shapiro MJ, Morey JC, Small
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psnet.ahrq.gov/node/34804/psn-pdf
January 05, 2017 - January 5, 2017
Cullen DJ, Bates DW, Small SD, et al. … The authors conclude that voluntary reporting mechanisms will capture only a small fraction of
ADEs
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psnet.ahrq.gov/node/44993/psn-pdf
April 17, 2017 - An AHRQ-funded toolkit
provides resources for small rural hospitals interested in implementing safety … patient-safety-indicators-overview
https://psnet.ahrq.gov/issue/implementing-program-patient-safety-small-rural-hospitals
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - An abdominal CT scan showed an obstructing foreign body in the small bowel, initially thought to be a … to deteriorate despite volume resuscitation, broad spectrum antibiotics, and attempts to reduce the small … autopsy, the entire Foley catheter—with inflated balloon and distal knot—was found to be obstructing the small … The catheter appeared to have been pulled into the small bowel by peristalsis. … Event: Because the Temporary Foley Catheter Was Not Secured Properly, It Became Displaced and Caused a Small
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psnet.ahrq.gov/issue/teaching-hospital-five-year-mortality-trends-wake-duty-hour-reforms
November 26, 2014 - Citation Text:
Volpp KG, Small DS, Romano PS, et al. … Facebook
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November 26, 2014
Volpp KG, Small … Copy URL
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Citation Text:
Volpp KG, Small
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psnet.ahrq.gov/node/45911/psn-pdf
June 27, 2018 - Prior studies have shown that a small proportion of physicians account for a
disproportionate share … Although the absolute increase in complication rates was relatively
small across all surgeons, surgeons