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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - .
• Indirect evidence of injury based on functional testing is sufficient to suggest a
tendon injury … working conditions is critical to patient safety, and in this case may include
adequate clinician rest, sufficient … a flexor
tendon laceration (i.e., inability to flex the thumb) suggests that the clinician lacked sufficient
-
psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - If ADMs are used, acquire sufficient numbers so that they can be placed in
close proximity to patient … Distractions and interruptions lead to medication errors; nurses should be allowed sufficient
uninterrupted
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psnet.ahrq.gov/node/41494/psn-pdf
June 27, 2012 - National Voluntary Consensus Standards for Patient
Safety Measures: A Consensus Report.
June 27, 2012
Washington, DC: National Quality Forum; June 2012.
https://psnet.ahrq.gov/issue/national-voluntary-consensus-standards-patient-safety-measures-consensus-
report
Progress in improving patient safety has been hampe…
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - effective execution of a care plan, but providers instead falsely assume that electronic communication is sufficient … communication between members of a patient care team is essential—electronic communication is not a sufficient
-
psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Therefore, ensuring sufficient follow-up and treatment to prevent kernicterus without excessive visits … of anemia (pallor, poor feeding, lethargy, respiratory distress), and weekly
follow-up is generally sufficient
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - Indirect evidence of injury based on functional testing is sufficient to suggest a tendon injury, and … working conditions is critical to patient safety, and in this case may include adequate clinician rest, sufficient … of a flexor tendon laceration (i.e., inability to flex the thumb) suggests that the clinician lacked sufficient
-
psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - need to complete a formal falls risk assessment as the
history alone for these two residents provides sufficient … regarding implementation
and use of interventions to decrease fall risk, while important, is not
sufficient … Education of residents, staff, or informal caregivers alone is not sufficient to
prevent falls and
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psnet.ahrq.gov/taxonomy/term/3460
September 15, 2025 - Swiss Cheese Model
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular …
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - need to complete a formal falls risk assessment as the history alone for these two residents provides sufficient … education regarding implementation and use of interventions to decrease fall risk, while important, is not sufficient … Education of residents, staff, or informal caregivers alone is not sufficient to prevent falls and should
-
psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - am) or in response to exogenous ACTH administration (ACTH stimulation testing), a low value is not sufficient … cortisol level (<5 ug/dl) paired with an ACTH level greater than two times the upper limit of normal is sufficient
-
psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - need to complete a formal falls risk assessment as the history alone for these two residents
provides sufficient … education regarding implementation and use of interventions to
decrease fall risk, while important, is not sufficient … Education of residents, staff, or informal caregivers alone is not sufficient to prevent falls and should
-
psnet.ahrq.gov/glossary/swiss-cheese-model
September 13, 2021 - Swiss Cheese Model
September 13, 2021
Anonymous (not verified)
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safe…
-
psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - the arthroscope, the surgeon determined that the ACL was only partially torn
and that the joint had sufficient … ) As
such, effective communication is largely dependent on efforts to ensure that individuals have sufficient
-
psnet.ahrq.gov/node/49670/psn-pdf
November 01, 2012 - requires integration of a number of symptoms and physical exam findings, as no
one symptom or sign is sufficient … No one symptom, sign, physical exam finding, or radiographic finding is sufficient to diagnose
pneumonia
-
psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - Is the lighting sufficient?
Are there convenient restroom facilities? … Is it of sufficient size to accommodate all required equipment?
-
psnet.ahrq.gov/node/33589/psn-pdf
September 15, 2024 - It is important to recognize that standardization is necessary but not sufficient for achieving resilient
-
psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - make the problem worse.16
Deepening the level of anesthesia with intravenous anesthetic agents may be sufficient … onset and relatively short duration of action.21 A dose of 10 mg administered
intravenously is usually sufficient
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - certification of competency may not sufficiently improve their skills; 2) training
personnel without sufficient … rate from
2.85 to 0.98 discrepancies per patient; interrupted time series analysis of the sites with sufficient
-
psnet.ahrq.gov/node/49530/psn-pdf
February 01, 2007 - based upon an antigen-antibody reaction involving the group-
specific carbohydrate of the cell wall, a sufficient
-
psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - certification of competency may not sufficiently improve their skills; 2) training personnel without sufficient … rate from 2.85 to 0.98 discrepancies per patient; interrupted time series analysis of the sites with sufficient