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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - use of continuous waveform capnography during moderate and deep sedation. 4,8 The use of waveform … The use of shared terminology is a critical component of closed loop communication. … via performance feedback and staff education demonstrated a significant increase in the use of closed-loop … Characterize the outcome adverse events as minimal, moderate or sentinel outcome. … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - placement of a vecuronium-containing syringe on the anesthesia drug tray by a previously assigned anesthesia … A uniform approach, on the other hand, creates a reliable framework that minimizes the risk of mistakes … A proper handoff report not only provides pertinent data about the patient, their condition, and case … risk of a poor outcome. … A randomized controlled trial on the effect of a double check on the detection of medication errors.
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - , cost, and antibiotic use.( 5,6 ) The Society for Healthcare Epidemiology of America advises against … The hazard of using additional data. JAMA. 1976;236:1259-1263. [go to PubMed] 3. … of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. … clinical outcome. … Impact of automated alerts on follow-up of post-discharge microbiology results: a cluster randomized
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - At Tenet, the staff at the corporate center would do the research on what the latest advances in patient … RW: What's the role of data when you're sitting centrally in a large organization? … The specialists have a target for next year to achieve 100% use of the ambulatory medical record. … by a reduction in mortality, acute renal failure, use of mechanical ventilation, length of stay, and … The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research
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psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - the safety and quality of oral healthcare, with a particular focus on using data for electronic health … since 2007 with a focus on trying to use data and informatics approaches to measure and improve the … records on the medical side, as well as a number of dental clinics, and they use the same electronic … able to use a module called Wisdom for dental care and all of their data will be together. … the safety and quality of oral healthcare, with a particular focus on using data for electronic health
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psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - of the handoff, and the expectations around the use of the information vary
depending on the setting … That is an outcome that none of us can accept. … So there's not a lot of outcome information. … than a decade to develop that data. … We would have the ability to conduct a
research project through all of the educational programs in that
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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - The sole use of physical examination (abdominal palpation) is unreliable in the diagnosis of an AAA, … benefit of one-time screening in women, and there is limited evidence on the benefits of repeat AAA … Had he undergone screening earlier, he might well have had a better clinical outcome. … The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic … Long-term outcome of open or endovascular repair of abdominal aortic aneurysm.
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - The amount of material that’s put in front of radiologists on a daily basis is, quite frankly, unsustainable … So I think in the oncology space there is an opportunity to use big data and AI to provide value to the … The truth and proof is in the use of pathology. … focus of this Perspective is on the use of AI in healthcare diagnostics, specifically imaging. … is a serious safety outcome for the patient. 7
Conclusion
Despite the potential of AI in diagnostic
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - The UK emergency laparotomy
network study identified variability in the use of postoperative critical … Administrative data from the UK has also
shown that increased provision of high dependency and intensive … Quality and safety on an acute surgical
ward: an exploratory cohort study of process and outcome. … Effect of a "Lean" intervention to
improve safety processes and outcomes on a surgical emergency unit … Effect of a comprehensive
surgical safety system on patient outcomes.
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - the data was first collected in 2020. 3 People who use substances (PWUS) may be at acute risk of harm … and technicians to interpret the results. 17,18 Research on the effectiveness of drug-checking on health … One important avenue for future research is evaluating the effectiveness of drug-checking services on … Implementation and uptake of the Massachusetts drug supply data stream: a statewide public health-public … That is a lot given that we have decades of data supporting the efficacy of these programs for reducing
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psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - The Commentary This patient's poor outcome occurred in part due to a breakdown in communication between … The transfer of patient data and care responsibility is commonly referred to as a "signout", "passoff … Verbal signout training and use of read-backs. … Use of information technology to assist in the information transfer. … The impact of a regulation restricting medical house staff working hours on the quality of patient care
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
April 19, 2023 - , a center focused on national, regional, and local quality improvement research and practical initiatives … in the country as our data collection platform. … Our primary outcome measure is a standard NSQIP hallmark outcome measure, the death or serious morbidity … Not everybody will in fact use all of the flexibility. … So when the interns use their flexible hours and flex up, typically they are doing sort of more mundane
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psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
March 01, 2013 - Cost: the missing outcome in simulation-based medical education research: a systematic review. … We consider a level one study as one where the outcome is measured in simulation. … The only way you would get out of doing simulation on a recurrent basis is if you retire from the business … the use of simulation to improve care. … DG : It really depends on where they believe they could use the most improvement.
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - This case presents a patient who is clearly at very high risk for suicide based on the presence of multiple … A rich body of research demonstrates that a diagnosable psychiatric condition contributes to death in … escalating use of alcohol or other substances. … Moreover, it does not afford medicolegal protection in the case of an adverse outcome.( 16 ) The current … In addition, the commentary does not include information regarding investigational or off-label use of
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - The data provided by a PA catheter is also complex and subject to misinterpretation, especially since … This type of rushed and difficult circumstance places a high premium on comprehensive, accurate communication … given a complete report to the resident (including a review of the current hemodynamic data on the monitor … One of the greatest dangers of their use is a permanent wedge with the balloon inflated that can cause … a patient injury through use of a checklist.
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - Broader use of insulin drips outside the ICU requires that safeguards be put in place to prevent a potential … Recent data support the practice of tighter control (through the use of IV insulin drips) in the surgical … The extent to which such data can be generalized to medical and surgical patients on the general medical-surgery … Quality improvement efforts that focus on increasing use of medications and "tight control" of physiologic … their medication use: an analysis of the NACC-UDS database.
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psnet.ahrq.gov/node/74242/psn-pdf
January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to
Prevent Missteps
January 7, 2022
Sauder C, Kleber … The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet
[internet]. 2022. … However, the patient was put at risk for an adverse event that could have affected the outcome of her … of use of a dual tracer
(Technicium-99 radiotracer and blue dye) decreases the surgeon’s ability to … Effect of a comprehensive surgical safety system on patient
outcomes.
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - Propose the use of checklists by rescuers at their institution to assess the readiness of the defibrillator … for high-use areas) equipment checklist should be completed by a member of the resuscitation team or … Rescuers should be trained on the device they are going to use and should have frequent hands-on experience … Rescuers should use checklists to assess the readiness of the defibrillator and its components on a daily … Outcome of out-of-hospital cardiac arrest in New York City: the Pre-Hospital Arrest Survival Evaluation
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - the safety and quality of oral healthcare, with a particular focus on using data for
electronic health … since 2007 with a focus on trying to use data and
informatics approaches to measure and improve the … ’t really able to use the data beyond clinical
care. … records on the medical side, as well as a number of dental
clinics, and they use the same electronic … able to use a module called Wisdom for dental care and all of their data will be together.
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psnet.ahrq.gov/node/33836/psn-pdf
June 01, 2017 - One study, using
data from Nationwide Inpatient Sample (a 20% representative sample of all nonfederal … Looking at 11 years of data, the researchers found significantly
better outcomes on weekdays.(8) The … a procedural intervention than
those admitted on the weekend. … , PhD Research Specialist Division of Cardiology Department of Radiolgoical Sciences
University of California … with acute myocardial infarction: results from the Global
Use of Strategies to Open Occluded Arteries