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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - placement of a vecuronium-
containing syringe on the anesthesia drug tray by a previously assigned … 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/node/49717/psn-pdf
September 01, 2014 - last
2–3 decades.(1,2) Although data regarding the prevalence of chronic opioid use in hospitalized … a patient on chronic opioids for acute pain, a thorough understanding of the nature or
quality of the … In addition, clinicians should be educated on the use of non-narcotic
analgesics either as first-line … the associated adverse outcome. … data from a large health system: opioid-related adverse events and
their impact on clinical and economic
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - The use of siderail(s) to prevent falls is controversial, especially if they are used as a restraint … use of the belt restraint. … Nursing University of California, Davis asatake@ucdavis.edu References Older Adult Falls Data. … History of falls and fear of falling are predictive of future falls: outcome of a fall rate model applied … A retrospective cross-sectional study on the risk factors of recurrent falls among inpatients.
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - Written protocols for the use of intravenous rtPA in acute stroke have been shown to be a key step in … 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/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - 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 … 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:
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - A lack of screening was a significant issue
identified in the eA process for AAA.1
Based on the eA/ … total of 12 eA/eB studies on a wide variety of topics, identifying many
needed system improvements. … A common outcome
of these methods is for the involved provider to increase their education and “be more … : a research consultant(s) who consult(s) with
clinical leaders on the disease being reviewed, and specialty … Adoption Considerations Use by Others (Use By Other Organizations)
Per the innovating organization,
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia … The Commentary
The use of tPA in acute ischemic stroke patients has been shown to improve the likelihood … As well, many institutions use a dedicated “stroke
team.” … The safe administration of tPA to patients with acute ischemic stroke depends on a well-functioning … data.
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psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - , and diabetes slipped on a rug at home and fell, fracturing his left hip. … For example, in the preoperative use of echocardiograms, a retrospective review of hip fracture patients … The interdisciplinary workgroup in charge of the protocol should have measurable process and outcome … Hospital leadership and data management support of this group are critical to success. … retrospective observational study on prospectively collected data from the Danish Fracture Database Collaborators
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - on the left and a persistent unchanged pleural effusion on the right. … Essentially the entire literature on this subject concerns resident physicians;
data on fully trained … One is the patient outcome resulting from the error, and the other is the degree of personal
responsibility … There are few quantitative data on the impact of disclosure to
patients on physician distress after … direct
causative role and the patient's poor outcome.
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - her to strike her head on the window. … Lapses in professionalism were not secondary to negligent acts on the part of the residents, but the … A new and sobering body of research shows that practice patterns developed in residency persist many … Few patient care or educational outcome studies have been done to formally evaluate this type of ambulatory … Frequent measurement and sharing of data are first steps to achieving a culture of shared responsibility
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - It's a cyclical process of data management. … A patient safety officer must have all those skills on top of the clinical skills and knowledge of evidence-based … On the other hand, with that kind of intelligence comes a degree of self-assurance and a perspective … In particular, the Quality and Safety Departments will need to coordinate their use of resources. … A mixed set of both outcome and process indicators would be helpful.
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psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - A lot of the falls research we conducted
from 2007 on was based on this hypothesis. … I look at this as a process measure. Falls rates are outcome measures. … Additionally, all the requirements are
available on our website, so really anyone can use them to get … Patricia Dykes: It is important to use both patient-reported and electronic health record data to identify … A lot of the manual screening that is done in primary care, could be
improved with EHR data and other
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health record. … I see the development of a journal. I see a research agenda. … All the numbers we have were based on research studies. … We saw that a lot in the research study I did of diagnostic errors. … So if you're relying on the physicians to use these products, they may not.
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - A lot of the falls research we conducted from 2007 on was based on this hypothesis. … I look at this as a process measure. Falls rates are outcome measures. … Additionally, all the requirements are available on our website, so really anyone can use them to get … A lot of the manual screening that is done in primary care, could be improved with EHR data and other … The use of remote patient monitoring via video from a centralized monitoring station within the hospital
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Data Science Institute, a part of
Ascension health system that provides data analytic support, determined … The use of surgical sponge counter bags are recommended but not required as
a bundle element.2 These … For example, implement the use of a “wingman”. … potential RSI events, and one outcome measure, rates of RSI harm
events. … for all team members to get a pulse on progress
toward the goal of zero RSIs.
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - The use of contrast typically enhances diagnostic accuracy with the potential increase in fetal harm … The use of the algorithm as well as the clinical outcomes of pregnant patients with abdominal pain should … led to an earlier diagnosis and a better outcome. … Same Author(s)
WHO research agenda on the role of the institutional safety climate for … January 7, 2015
ASHP guidelines on the safe use of automated dispensing devices.
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - 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 … The reaction highlights the importance of training all staff, even nonclinical staff members, on the … escalating use of alcohol or other substances. … an adverse outcome.(16) The current recommendation is to use a simple process referred to as
safety
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - preventable adverse event except for
the outcome. … settings, but a growing body of research documents that preventable harm is common in all sites of … research, resulting in some of the most prominent successes in the safety field. … Their efforts focus on
enhancing patient and caregiver engagement, tracking and sharing safety data, … There is now a general consensus that the field
should shift from focusing on single types of adverse
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - On a national level, the rate of staphylococci in intensive care units that are methicillin resistant … A more detailed summary of these prevention strategies is available on the Centers for Disease Control … A complete review of the controversy regarding culturing patients on admission to the hospital is beyond … However, there is considerable evidence to support the use of active surveillance cultures for identifying … It is short-sighted for a hospital to focus their efforts on the control of just one organism, since
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - Scripts and tools to facilitate ongoing data literacy training (e.g., daily use of a huddle sheet for … Use By Other Organizations
Other hospitals are using the A-F bundle, but not the data literacy training … the use of the wrong plan to achieve an aim. … Scripts and tools to facilitate ongoing data literacy training (e.g., daily use of a huddle sheet for … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter