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psnet.ahrq.gov/issue/hsib-maternity-investigation-programme-year-review-202122-summary-highlights-themes-and
September 14, 2022 - April 1, 2019
Investigation into Management of Venous Thromboembolism Risk in Patients
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psnet.ahrq.gov/issue/10-state-project-study-methods-reduce-central-line-associated-bloodstream-infections-hospital
October 23, 2019 - May 25, 2011
Elimination of central-venous-catheter-related bloodstream infections from
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psnet.ahrq.gov/issue/never-events-analysis-hsibs-national-investigations-report
June 09, 2021 - April 1, 2019
Investigation into Management of Venous Thromboembolism Risk in Patients
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psnet.ahrq.gov/issue/administering-high-strength-insulin-pen-device-hospital
September 21, 2022 - April 1, 2019
Investigation into Management of Venous Thromboembolism Risk in Patients
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psnet.ahrq.gov/issue/investigation-electronic-prescribing-and-medicines-administration-systems-and-safe-discharge
April 01, 2019 - January 22, 2020
Investigation into Management of Venous Thromboembolism Risk in Patients
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psnet.ahrq.gov/issue/maternity-pre-arrival-instructions-999-call-handlers
February 16, 2022 - April 1, 2019
Investigation into Management of Venous Thromboembolism Risk in Patients
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-tooth-extraction
April 01, 2019 - September 29, 2021
Investigation into Management of Venous Thromboembolism Risk in Patients
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psnet.ahrq.gov/issue/speaking-being-heard-registered-nurses-perceptions-workplace-communication
June 12, 2019 - November 13, 2024
Central venous catheter guidewire retention: lessons from England's
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psnet.ahrq.gov/issue/building-culture-safety-health-care
April 15, 2021 - June 14, 2023
Safety Risk of Air Embolus Associated with Central Venous Catheters Used
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psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein
January 22, 2020 - May 17, 2023
Investigation into Management of Venous Thromboembolism Risk in Patients
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - The patient remained on metoprolol and simvastatin in addition to enoxaparin for deep venous thrombosis … In a prospective regional study of 580 patients, no patient who received venous thromboembolism prophylaxis … category: the patient was appropriately risk stratified prior to surgery, she received prophylaxis for venous … pneumothorax Pneumothorax ("collapsed lung") due to a procedure such as insertion of a central venous
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psnet.ahrq.gov/issue/wise-event
October 09, 2024 - 'Matching Michigan': a 2-year stepped interventional programme to minimise central venous
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psnet.ahrq.gov/issue/applying-trigger-tools-detect-adverse-events-associated-outpatient-surgery
November 10, 2015 - Venous thromboembolic events and emergency department triggers appeared the most promising to identify
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psnet.ahrq.gov/issue/what-nhs-safety-thermometer
November 02, 2016 - track incidents involving pressure ulcers, falls, urinary infections in patients with catheters, and venous
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psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-report-2015
November 23, 2016 - quality of care has improved over time for myocardial infarction, pneumonia, surgery, pediatric asthma, venous
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psnet.ahrq.gov/issue/listening-learning-responding-concerns
June 12, 2024 - March 11, 2020
Safety Risk of Air Embolus Associated with Central Venous Catheters Used
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psnet.ahrq.gov/web-mm/paradoxical-pulse
May 01, 2013 - hours spent by students, residents, and faculty gazing at neck veins, the overall accuracy of jugular venous … pressure (JVP) in predicting low, normal, or high central venous pressure is only 56%.( 2 ) The presence … Does this patient have abnormal central venous pressure? JAMA. 1996;275:630-634.
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - and well-proven intervention that markedly reduces the
risk of both first and recurrent arterial and venous … of three months of anticoagulation with extended
anticoagulation for a first episode of idiopathic venous … Randomized assessment of a
warfarin nomogram for initial oral anticoagulation after venous thromboembolic
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psnet.ahrq.gov/issue/iom-panel-reviews-lessons-medication-safety
September 30, 2009 - August 26, 2020
Central venous catheter guidewire retention: lessons from England's never
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psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010-2015-interim-data-national-efforts
December 24, 2008 - events, pressure ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous