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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - use of checklists and timeouts. … Previous research in this area has focused almost exclusively on factors in the hospital environment. … remains the focus of ongoing research. … The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center … The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - and “store and forward” of clinical data collected, including data from the electronic health record … Such a platform is able to aggregate all data allowing the
dentist to remotely evaluate the patient … While the pandemic has necessitated its use, more research is
needed to help determine the technology … Important research priorities may include estimating the costs and benefits of expanded PPE use (and … Effect of different concentrations of sodium hypochlorite on
outcome of primary root canal treatment
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psnet.ahrq.gov/node/47097/psn-pdf
June 26, 2018 - five prescribers or more than five pharmacies) in a manner conceptually similar to trigger tools. … Patients with any of these opioid use triggers were significantly more likely to experience an overdose … within the next 6 months. … These results provide insight on how best to use data from prescription drug
monitoring programs, which … are now widely used as a tool in combating the opioid epidemic.
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - I will, however, use this case to
discuss the concept of authority gradients and how they relate to … On rounds,
the student presented this new data, including the account of the Foley placement in the … provide a very
important snapshot across a number of dimensions, and I strongly encourage their use … Or does the hospital CEO (and the surgeon) take a moment to pat her on the back, making
it clear that … The University of Texas Center of Excellence for Patient Safety Research and
Practice.
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - The anesthesiologist kept the patient oxygenated and asleep while attempting to use
a fiberoptic bronchoscope … a patient history and physical examination on the day of surgery. … On top of that, the patient was not seen in a preanesthesia clinic for evaluation and
review of his … on the day of surgery. … Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - The outcome was not ideal and there was apparently a lot of shouting and some blaming. … stress.3 Evidence supporting the use of debriefing as a
core component of simulation education was … and objective data, inquiry into the mindsets of those present, and clarification of takeaway points … Recent literature suggests the utility of a charge nurse
or shift leader simply ‘checking in’ on the … Group norms of going around the circle giving each person the opportunity to
share or use of a “talking
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - As a result, the diagnosis was not revisited, even in the presence of contradictory data,
leading to … tools to screen for potential errors (9)
may hold some promise, but more research on measurement is … On the other hand, if a lesion is found by CT, an MRI to better define the
anatomy and pathology of … Some have advocated for
the use of generic metacognitive strategies (e.g., knowledge of error theory … Some authors have advocated for use of the status "not yet diagnosed" to denote cases where the
diagnosis
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psnet.ahrq.gov/print/pdf/node/74279
January 01, 2022 - on Healthcare
Associated Conditions
Curated Library
All Library Content
The impact of coronavirus … disease 2019 (COVID-19) on healthcare-associated infections in 2020: a
summary of data reported to the … The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical … Based on a national sample of hospitals, this study explored the impact of hospital
visitation restrictions … Based on retrospective data, the
authors of this study did not identify a...
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - Perhaps then you can use your time to spend on the
patients and the issues where you have little common … and the amount of data that gets
transferred? … from not having a handoff-sensitive outcome that we can
observe. … Our data does show that some
people do recognize the tradeoff. … As we get more savvy thinking about how to do this research, we can also think about
how to use that
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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - of Robotics in Surgery
The use of robotic assistance in surgery has expanded exponentially since it … The data has generally
been equivocal in this area; standardized, comparable, long-term data are lacking … .(10) A study using
surveillance, epidemiology, and end results Medicare claims data compared open to … Hussain A, Malik A, Halim MU, Ali AM. The use of robotics in surgery: a review. … Systematic review and meta-analysis of studies reporting
oncologic outcome after robot-assisted radical
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - In the second case, maybe the pharmacist should have demonstrated the use of this unique nasal medication … effects of the drugs on the patient. … It's supposed to be a warning, but we actually use it as an indicator of how far to go. … RW: Our hospital had an error with the use of a defibrillator a while back, and we found there were … The machines require a standardization of data input that hospitals don't have.
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psnet.ahrq.gov/node/43801/psn-pdf
August 02, 2015 - Association of the 2011 ACGME resident duty hour reform
with general surgery patient outcomes and with … Association of the 2011 ACGME resident duty hour reform with
general surgery patient outcomes and with … from the American College of Surgeons National Surgical Quality Improvement Program. … Researchers applied difference-in-differences analysis, which can account for some of the uncertainty … of
nonrandomized data, a common concern in patient safety research.
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psnet.ahrq.gov/node/47648/psn-pdf
February 27, 2019 - Comparing the outcomes of reporting and trigger tool
methods to capture adverse events in the emergency … adverse
events in the emergency department of an academic medical center over a 1-year period. … In keeping with prior research, the authors conclude that the use of a combination of methods
for capturing … harm is more effective than the use of a singular approach. … A past PSNet perspective
highlighted the importance of feedback with regard to incident reporting.
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psnet.ahrq.gov/node/47240/psn-pdf
March 06, 2019 - Improving detection of intraoperative medical errors
(iMEs) and intraoperative adverse events (iAEs) … intraoperative errors and adverse events reported by physicians
through both surgical debriefings and the … They found a positive
association between the presence of intraoperative events and increased postoperative … In keeping with prior research, the authors conclude that using multiple sources of data provided a … more comprehensive picture of safety during surgery.
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - Written protocols for the use of
intravenous rtPA in acute stroke have been shown to be a key step in … clinical data
necessary to make a decision regarding acute reperfusion therapy. … The safety and efficacy of rtPA in routine clinical use has
been subsequently confirmed in a large cohort … door-to-needle time for the use of intravenous rtPA should
not exceed 60 minutes.(16) A primary stroke … The patient in a coma (item
1a=3) will automatically score 3 on this item.
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psnet.ahrq.gov/node/846770/psn-pdf
March 29, 2023 - and therapeutic purposes, with continued expansion of
its use as a safer alternative to traditional … (23% versus 45%), and a 35% decrease in mean
length of hospital stay (13 versus 20 days).5 These data … with subsequent triage to a surgical or medical service, depending on the results of imaging. … Impact of trainee involvement on the outcome of ERCP
procedures: results of a prospective multicenter … Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/node/46302/psn-pdf
December 22, 2017 - In this retrospective study, researchers
analyzed data from the National Poison Database System. … The study found an average rate of these types of medication errors of 1.73 per 100,000 people. … Death was reported in 0.6% of cases. … In keeping with prior research, the most frequently reported types of
medication errors included dosing … A previous WebM&M commentary described a
near miss in which a patient almost administered the wrong
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - The case was reviewed in light of the tragic outcome. … In this
particular case, the overnight read by the resident was based on a comparison of the current … study with the
results on the text report of the prior dissection. … report of a prior film to
compare with the current images) on which to base his or her current assessment … the broader systems flaw before it led to
a tragic outcome.
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psnet.ahrq.gov/node/33835/psn-pdf
June 01, 2017 - His research is internationally recognized for using
routine data to identify disparities in quality … We decided
to use our large resource of administrative data and look at this in England. … So you would get the same kinds of operations on a Monday as you would expect on a Friday. … We looked at the proportion
of patients who could expect to get a brain scan on the day of admission … We're beginning to use some of that data linked to hospital data to learn
more about the patient journey
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psnet.ahrq.gov/node/45564/psn-pdf
October 03, 2017 - https://psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-and-costs
The lack of effective … This commentary recommends ways to enhance the use of quality and safety measures, including
establishing … an entity responsible for setting health data standards, developing a robust scientific approach
to … performance measurement, and improving how this data is communicated to patients. … fostering-transparency-outcomes-quality-safety-and-costs
https://psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers