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21. In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring | PSNet
    psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
    April 26, 2023 - Our role is to analyze data related to patient safety, especially monitoring of general care patients … into the medical record with a press of a button. … This function saves a lot of time to capture and record vital signs. … line as the system processes the sensor data. … To address this issue, the alarming system for surveillance monitoring is notably different from other

22. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
    psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
    April 26, 2023 - While this may be the current standard of care in most hospitals, it is rare that staff are monitoring … To address this issue, the alarming system for surveillance monitoring is notably different from other … into the medical record with a press of a button. … This function saves a lot of time to capture and record vital signs. … line as the system processes the sensor data.

23. Antibiotic and Opioid Stewardship in Dentistry | PSNet
    psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
    December 07, 2020 - 20% of all antibiotics prescribed by dentists in the US. 1 , 2  Clindamycin is associated with an increased … We also used behavioral nudges to influence prescribing, including posters provided by the CDC, targeting … For the fourth core element, tracking and reporting, we provided some data back to the dental staff to … We looked at this same data post-implementation and antibiotic prescribing decreased by 70% post implementation … In this intervention, the patients were instructed on what to expect post extraction, we provided non-opioid

24. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49638/psn-pdf
    January 01, 2012 - of record for this admission. … Yet, if that is all that happened, the next child in this same condition in this same institution will … The intensivist must weigh the data and move patient care forward by directing and focusing a team of … So in this case the issue of who was "in charge" is quite real. … of record; someone must be in charge.

25. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49732/psn-pdf
    May 01, 2015 - The bundle, recently updated in 2013 by the Surviving Sepsis Campaign (SSC) and endorsed by multiple … To mitigate this, the use of a sepsis screening tool is recommended by the SSC. … When the patient's chart is subsequently entered by a nurse or other provider, the alert stating the … Hospital data can be collected and analyzed and feedback on performance should be provided to individuals … septic shock and the need for a systematic approach to this disorder.

26. Communication Failure—Who's in Charge? | PSNet
    psnet.ahrq.gov/web-mm/communication-failure-whos-charge
    April 01, 2018 - record for this admission. … Yet, if that is all that happened, the next child in this same condition in this same institution will … The intensivist must weigh the data and move patient care forward by directing and focusing a team of … So in this case the issue of who was "in charge" is quite real. … of record; someone must be in charge.

27. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
    psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - safety in numbers is true for procedural sedation. … For example, potassium supplements for a patient on furosemide is routine, however, this same drug may … of confused drug names . 34–38 The use of shared language and terminology—in this case dose units—is … World SIVA adverse sedation event-reporting tool. 45   Data collected by event … in this report.

28. New Insights on Safety and Health IT | PSNet
    psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
    August 01, 2015 - This process of supporting the cognitive needs of the user in health care is further complicated by the … and Management Systems Society (HIMSS) Electronic Health Record Association, and this is a hopeful trend … Those analogies turn out to be extremely useful because they tell you that there is a path by which this … This creates a situation that sometimes is called vendor lock-in, where once you've made the choice to … Vendor lock-in gets in the way of what you really want to see, which is a set of pressures for delivery

29. Errors in Sepsis Management | PSNet
    psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - The bundle, recently updated in 2013 by the Surviving Sepsis Campaign (SSC) and endorsed by multiple … To mitigate this, the use of a sepsis screening tool is recommended by the SSC. … When the patient's chart is subsequently entered by a nurse or other provider, the alert stating the … Hospital data can be collected and analyzed and feedback on performance should be provided to individuals … shock and the need for a systematic approach to this disorder.

30. In Conversation With… Robert M. Wachter, MD | PSNet
    psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
    August 01, 2015 - Those analogies turn out to be extremely useful because they tell you that there is a path by which this … Vendor lock-in gets in the way of what you really want to see, which is a set of pressures for delivery … This process of supporting the cognitive needs of the user in health care is further complicated by the … cookie-cutter approach, and we need to preserve room for innovation by vendors and customization by … and Management Systems Society (HIMSS) Electronic Health Record Association, and this is a hopeful trend

31. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - another part of the hospital (as in this case). … Unfortunately, as is possibly true in this case, telemetry monitoring may be seen by the prescriber … is beyond the scope of this commentary.) … the source for this information? … How often and through what means (e.g., telephone, in person, electronic health record) is report given

32. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/848124/psn-pdf
    April 26, 2023 - Our role is to analyze data related to patient safety, especially monitoring of general care patients … them into the medical record with a press of a button. … This function saves a lot of time to capture and record vital signs. … Another issue is when travel nurses come in who weren’t onboarded to the rationale for the wide alarms … line as the system processes the sensor data.

33. In Conversation With... Jack Westfall, MD, MPH | PSNet
    psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
    September 28, 2022 - JW: The electronic health record (EHR) is a great tool for being able to ascertain people’s status on … documented in the medical record. … I think the move to electronic health records is a great example of this double-edged sword of a tool … provided.” 28 For example, take a patient who has hypertension that is controlled and who has good … ’s health is in jeopardy, and there is high potential for resultant harm in this context.

34. What Happened on Telemetry? | PSNet
    psnet.ahrq.gov/web-mm/what-happened-telemetry
    January 18, 2012 - part of the hospital (as in this case). … Unfortunately, as is possibly true in this case, telemetry monitoring may be seen by the prescriber or … is beyond the scope of this commentary.) … the source for this information? … How often and through what means (e.g., telephone, in person, electronic health record) is report given

35. Dependence vs. Pain | PSNet
    psnet.ahrq.gov/web-mm/dependence-vs-pain
    October 30, 2019 - provided. … Unfortunately, the terminology for this disorder is confusing. … in my bones"), but overt abdominal pain (as seen in this case) is less common. … Partly for this reason, opiate withdrawal is generally managed in the outpatient setting in methadone … December 2, 2020 Effect of restriction of the number of concurrently open records in

36. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867986/psn-pdf
    March 24, 2025 - This is being emphasized more now than it used to be in the past. … The health system I work in, as well as other organizations, have published data showing that when you … By comparison, when people screen for hypertension, the method is the same, no matter where you are. … For example, you can develop tip sheets or build tools into the electronic health record that can quickly … Most often, when a person dies or gets seriously injured in a unit, they use something that is available

37. The Media’s Role in Patient Safety | PSNet
    psnet.ahrq.gov/perspective/medias-role-patient-safety
    April 27, 2022 - The impetus for change was reporting by the news media that made it clear that improvements in patient … The potential of Twitter as a data source for patient safety. … This is also when I became interested in quality of care. … This is where some of the great work I’d like to see featured in the media becomes invisible. … to state those things on the record.

38. In Conversation With… Abraham Verghese, MD | PSNet
    psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
    November 01, 2012 - One populates the physical diagnosis part of the medical record by filling in dropdown boxes, and no … physicians and patients, that somehow got lost in this conversion to electronic medical records, again … How important are the stories and how important is it going to be to have cold hard data, for example … It doesn't matter if the data is filtered. … pericarditis is difficult and often delayed.( 2 ) Why was it missed for so long in this patient?

39. In Conversation With... Michael L. Millenson | PSNet
    psnet.ahrq.gov/perspective/conversation-michael-l-millenson
    April 27, 2022 - This is also when I became interested in quality of care. … Articles in the medical literature may be stories, but mostly they’re about facts, provided within a … This is where some of the great work I’d like to see featured in the media becomes invisible. … to state those things on the record. … The potential of Twitter as a data source for patient safety.

40. The Evidence-Based Physical Examination as a Patient Safety Practice | PSNet
    psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
    November 01, 2012 - pericarditis is difficult and often delayed.( 2 ) Why was it missed for so long in this patient? … One populates the physical diagnosis part of the medical record by filling in dropdown boxes, and no … physicians and patients, that somehow got lost in this conversion to electronic medical records, again … How important are the stories and how important is it going to be to have cold hard data, for example … It doesn't matter if the data is filtered.