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psnet.ahrq.gov/node/49611/psn-pdf
October 01, 2010 - Empty bottles of both were found on the floor near the patient at his home, and it
was presumed that … he had overdosed on the medications as a suicide attempt. … a given year and 6% have a serious mental illness that significantly impairs their
life.(1,2) The data … Data suggest that 3
to 5 times the therapeutic dose (about a 2-week supply) is potentially lethal in … that
increase the risk of toxicity include advancing age, cardiac status, and concomitant use of other
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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - .( 3 , 6 , 7 ) This current and well-publicized body of research has focused on the ability of patients … arthritis and a score of 6 out of 10 on their pain scale, we need to ensure that the patient knows the … Whatever the goal is, the idea is to determine that goal a priori and use the teach-back until the … But they have not been very robust studies, and a lot of the potential benefit depends on the financial … data system.
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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/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - to the reporting of workplace violence events and the collection of workplace violence event data. … Because research on workplace violence is emerging, we need to focus on both the substantive areas … Jones: The research emerging from local facilities and systems around the use of technologies, applications … The world around technology and the use of AI is ripe for future research. … violence, based on research supported through the Agency for Healthcare Research and Quality (AHRQ),
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - to the reporting of workplace violence events and the collection of workplace violence event data. … Because research on workplace violence is emerging, we need to focus on both the substantive areas … Jones: The research emerging from local facilities and systems around the use of technologies, applications … The world around technology and the use of AI is ripe for future research. … violence, based on research supported through the Agency for Healthcare Research and Quality (AHRQ),
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - In the space of only a few years, we have pivoted smartly on this issue and, in part through your research … , and a smattering of tricyclics and so on. … There is a role for the use of opioids in the treatment of chronic pain. … data: a systematic review. … data: a systematic review.
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - This would
include the sorting of patient data, interpretation and weighting of the data, framing the … The attending
should know everything that happens to the patient and collect enough of the primary data … The degree of close supervision must be based on an assessment
of the skills, knowledge, and clinical … Effects of admission to a teaching hospital on the cost and quality
of care for Medicare beneficiaries … Agency for Healthcare
Research and Quality (AHRQ), U.S.
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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/60746/psn-pdf
July 29, 2020 - The initial physician evaluating the patient was an intern on their first day of service in a busy Emergency … The sonographer did not recognize that the patient was in her third trimester based on a review
of the … height of a third trimester pregnancy on physical exam. … (OB/GYN), which re-
interpreted the discrepant data, and resulted in a correct assessment and appropriate … Perspectives on Safety. Patient Safety Network. Agency for Healthcare Research and Qualtiy.
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - On inspection, the tracheal cuff had burst, leading to a severe leak in addition to a tracheal tear with … the cuff, malpositioning of the tracheostomy, corticosteroid use, tracheal infection, and tracheostomy … data to drive improvement. 13 The use of tracheostomy care bundles and multidisciplinary tracheostomy … A group of tracheostomy experts should be enlisted to agree on standards of care, to serve as a resource … October 19, 2022
The effect of clinical experience on the error rate of emergency physicians
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - based on the available evidence, regardless of patient harm.( 16 ) This definition helps identify, on … Making a diagnosis often involves shades of gray, rather than black and white data points. … Similarly, the use of treatment protocols or algorithms may reduce the risk of error.( 12 ) Ensuring … In addition, the commentary does not include information regarding investigational or off-label use of … Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.
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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