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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - The data provided by a PA catheter is also complex and subject to
misinterpretation, especially since … 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 … of a
patient injury through use of a checklist. … Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/node/33793/psn-pdf
November 01, 2015 - It gives you a general lay of the land, but it's not a
very good outcome to use to look at progress. … study adverse event outcome. … In clinical research, we don't use
some general measure of heart health. … How has the electronification of the literature and the
ability to collect data electronically changed … I
would say that as a journal editor, social media and the impact that has had on research dissemination
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship … Burnout and Safety Outcomes
Most of the research on the relationship between burnout and patient safety … outcomes has used self-reported perceptions of patient safety, an important but relatively weak outcome … A 2015 article described the use of a combination of theory-based principles, drawn from mindfulness … While data for the effects of coaching in health care settings are limited, coaching has been reported
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Data Science Institute, a part of Ascension health system that provides data analytic support, determined … For example, implement the use of a “wingman”. … For example, implement the use of a “wingman”. … for all team members to get a pulse on progress toward the goal of zero RSIs. … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - , including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative … We do a lot of quality improvement and research work with clinical data. … Tell me a little bit more about what a trigger tool is, what kind of data that might use, and what that … data on the SOPS? … EMS clinical data based on a national EMS data standard, the National EMS Information System, or NEMSIS
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Little published data describe the clinical presentation of aortic dissection in pregnancy. … Careful attention to the differential diagnosis, appropriate consultation and the judicious use of diagnostic … tragic outcome. … The mother and fetus in this case suffered a tragic outcome at a hospital that appeared to lack a structured … Healthcare
Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - While this indication was reasonable, the severe bleeding and rare outcome of
death encountered in this … Thus,
the use of liver biopsy must always be individualized. … cutoffs for INR or platelet count, or its impact on
the performance of liver biopsy. … The risk of bleeding and death
are likely higher in certain groups of patients, though available data … need for clinical and laboratory research.
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - first 48 hours.3 Research shows that the majority of ICU transfers are
thought to be avoidable.1,5,6 … ’s EHR and assigns an AAM score.7 The
model uses a variety of clinical data, including composite scores … An analysis of program data during this period indicated a patient reached the alert
threshold during … action steps:
Convene a multidisciplinary team of clinicians to review and use evidence-based criteria … Review and share program data on a consistent basis to guide performance improvement activities
to continue
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - The operative note commented on repair of the right side of the hysterotomy after delivery of the fetus … this outcome. … Use of Maternal Early Warning Trigger tool reduces maternal morbidity. … August 8, 2012
The impact of a computerized physician order entry system on medical errors … Influence of observation on the error rate.
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psnet.ahrq.gov/web-mm/central-line-clot
August 04, 2021 - heart rate of 120, a RR of 35, and an O2 sat of 90% on 100% non-rebreather. … To date, the best evidence for preventing catheter-related thrombosis in children supports use of heparin-bonded … Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry … Benefit of heparin use in central venous and pulmonary artery catheters: a meta-analysis of randomized … heparin exposure
LMWH prophylaxis
No data on efficacy in children
Heparin-bonded
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - on the left
side. … The operative note commented on repair of the right side
of the hysterotomy after delivery of the fetus … this outcome. … Use of Maternal Early Warning Trigger tool reduces maternal
morbidity. … Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - cases because there is more public data available on this class of retained surgical item. … The actual data tells a
different story. … of the lap pad on the x-ray. … having a correct count,
involved the use of a sponge counting device. … The more common outcome of an incorrect count called at the end of the case, when good
communication
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - Case & Commentary: Part 1 A 56-year-old man with a long history of heroin use presented to the … use of oxycodone products.( 6 ) Furthermore, according to the DAWN Mortality Data Report, hydrocodone … We are told that the patient in this case has a long history of heroin use and likely suffers from the … .( 32-34 ) Considering the effects of alcohol and other drug use disorders on patients and their environment … Overview of 5-year followup outcomes in the drug abuse treatment outcome studies (DATOS).
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - the evidence and large number of research studies showing the benefits of RPM. … Preliminary research on the value of RPM shows that there is cost-effectiveness when using RPM to manage … Evidence and recommendations on the use of telemedicine for the management of arterial hypertension: … You have to take a bird's eye view of the data. … Engagement is probably the most important part of RPM moving beyond the actual clinical outcome—engaging
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - use of existing data sources to identify opportunities to improve the delivery and safety of medical … Other limitations in the use of administrative diagnostic data include the incomplete collection of conditions … the use of diagnoses from billing data as a source of quality measurement for public reporting and pay … Administrative data based patient safety research: a critical review. … outcome measures.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - providers struggled to explain the outcome. … In fact, it is one of 20 "high-level hospital indicators" on the Agency for Healthcare Research and … Ultimately, as a matter of local quality improvement and assessment, I come down on the side of the … in the eyes of the public as evidence of egregious care to justify its use as a publicly reported … Measures of Patient Safety Based on Hospital Administrative Data—The Patient Safety Indicators.
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - The American Academy of Pediatrics (AAP) guidelines are
available on the Web. … First, maternal blood typing and use of Rho(D)
immunoglobulin have made maternal Rh isoimmunization … to prevent
the outcome in this case) was clearly indicated. … We wonder if part of the family's dissatisfaction in this case (which had a
fine outcome) was related … Research and Quality (AHRQ), U.S.
-
psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - In fact, data on sales and distribution of opioids
per person, per year, show an increase from 96 mg … , the dramatic rise in use of therapeutic opioids is not based on evidence of their long-term
efficacy … programs (statewide electronic
databases) that collect data on substances dispensed in the states may … :
striking the right balance to achieve the optimal public health outcome. … Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education.
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - the initial failure to suspect and investigate for CS was the primary cause of the poor
outcome. … A systematic review evaluating the commonly accepted clinical
signs of CS (i.e., pain, pain on passive … American Academy of
Orthopaedic Surgeons’ (AAOS) “Appropriate Use Criteria (AUC) Summary” on the diagnosis … some authors advocate the use of
an absolute ICP greater than 30 mmHg. … described the use of an algorithmic approach (seen here) to screen patients for CS using a combination
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - , which clearly was subpar and led to an adverse patient outcome. … Good data are not available on rates of adverse events associated with anesthesia handoffs. … the bevel of the needle, using excessive force in removing or threading the catheter, improper use of … And providers will be trained to do it, perhaps best via simulation.( 9,10 ) The data elements of a … Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: