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psnet.ahrq.gov/issue/effect-computerized-physician-order-entry-medication-prescription-errors-and-clinical-outcome
May 15, 2013 - Review
The effect of computerized physician order entry on medication prescription … The effect of computerized physician order entry on medication prescription errors and clinical outcome … This systematic review builds on the existing literature by examining the impact of CPOE in pediatric … The effect of computerized physician order entry on medication prescription errors and clinical outcome … on the number of pharmaceutical interventions among patients discharged from the hospital.
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - falls,14,15 one with a meta-analysis,15did not find any evidence to support the use of
chair or bed … might cause more rapid treatment after a fall.9 The evidence for use of, or avoidance of,
bedrails … use of
bedrails as a restraint.16 Further, there is no significant evidence to support the use of Vitamin … While there is still some
controversy on the use of full bed rails, if they were present, they may have … Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/node/50615/psn-pdf
October 30, 2019 - The largest study of a consecutive series of John Does (1) concluded that alias use is highly
associated … For example, an unknown male patient admitted on the 24th of April at the start of
a new name cycle … Concerns about accurate identification and the “unintended” consequences of Doe use stretch back to the … consequences of Doe use in the
era of the EHR will continue to focus on catching, as opposed to preventing … The John Doe syndrome: Diagnosis and outcome of patients unidentified at the time of
emergency department
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psnet.ahrq.gov/node/33882/psn-pdf
June 01, 2019 - outcome. … The field of resilience engineering focuses
on learning proactively about how things usually go well … Method being the most common.(9,10) However, the majority of resilience
engineering research has focused … on identifying how resilience manifests in different work systems rather
than on building a comprehensive … Resilience engineering: current status of the
research and future challenges.
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - incident reporting has led to improvements in safety, making the best possible use of the information … is likely to increase the use of reporting systems, increasing the absolute number of reports has been … Additional research on the safety action feedback loop would be valuable, but leaders wishing to improve … Shojania is a leading expert on evidence-based patient safety strategies and translating research into … That's a very structured type of data collection.
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psnet.ahrq.gov/node/33799/psn-pdf
January 01, 2015 - 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 measure. … 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 … Research over the past year helped strengthen this link and
thus enhanced the case for addressing burnout
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psnet.ahrq.gov/node/49643/psn-pdf
December 01, 2011 - to provide him with the 2010 evidence-based guidelines on the use of plasmapheresis in
Guillain-Barré … , requiring a longer hospitalization
and use of the indwelling catheter, which led to a serious infection … This means that a focus on the harms rather than the costs of
unnecessary, non–evidence-based care may … Clinicians should consider whether they could achieve the same outcome (treatment of GBS) with
less … Involving patients in clinical decisions:
impact of an interactive video program on use of back surgery
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. … thrombosis (DVT) involving the axillary and subclavian veins on the side of the PICC. … of infection.(6,7) There are no data comparing the incidence of ICVP-related
infection during acute … outcome. … Complications associated with the use of Port-a-Caths in
patients with malignant or haematological disease
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - STROKE IN A PATIENT WITH A HISTORY OF
SEIZURES
This case highlights the importance of timely use of … This trial demonstrated an overall benefit in functional outcome at 90 days, with
49% of treatment group … This trial also showed a benefit in functional outcome
at 90 days, with 45% of treatment group versus … Routine Use of CT Angiography and Perfusion Imaging (3)
25
• Reliance on the NIHSS as a trigger to … In pooled
patient-level data from 5 clinical trials, the odds of better disability outcomes at
90 days
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psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
February 26, 2025 - There's a lot of data, templates, and imported macros. … I think putting patients on the other end of notes is a little bit of a social nudge. … At the end of the year, there was a single "yes or no" primary outcome: Would patients and doctors want … One other illuminating data point from that initial study was that 85% of patients said they would use … It's called "The Cost of Technology"—at least the way we often use it now.
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psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - of modern-day alarm management and the hazards of alarm fatigue.( 1 ) Research has shown that 80%–99% … RW : You've done a lot of research on this issue and found some startling statistics. … When you buy a smartphone you leave the store and you figure out how to use it pretty much without any … In other words, it's taking into account a huge amount of big data, the context of the patient, the context … for patient outcome.
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - The Commentary This otherwise healthy young man presented initially with a pustule on his left buttock … primary outcome of clinical cure whether patients received antibiotic or placebo.( 14-16 ) The IDSA … Based on currently available published literature and data presented in this case study, it is unclear … that the use of clindamycin, to which the organism was not susceptible, led to progression of this patient's … The IDSA guidelines recommend use of adjunctive antibiotic therapy after incision and drainage in cases
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - The patient was connected to a cardiac monitor on a crash cart, which showed polymorphic ventricular … The Commentary The almost fatal outcome in this case directly resulted from treatment with high and … The limited mental status data provided in the case summary made the need for rapid and deep sedation … Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients. … (s)
The effects of on-duty napping on intern sleep time and fatigue.
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - 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
indicator … Measures of Patient Safety Based on Hospital
Administrative Data—The Patient Safety Indicators.
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - a high volume of patients on PN and adheres to the recognized national guidelines.( 10 ) Their staff … on a standard formula. … If any of the ingredients listed on the label are out of sequence or have a different dose or units than … The use of a CPOE system with decision support that interfaces with the pharmacy computer system thereby … Clinical outcome in patients from a single region who were dependent on parenteral nutrition for 28 days
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psnet.ahrq.gov/node/33784/psn-pdf
April 01, 2015 - use of surgical safety checklists, or at least reporting the extent of the use of surgical
safety checklists … If you do a before-and-after
study on use of a surgical safety checklist, in the typical design, people … Patients who have a partially completed
checklist have a better outcome, but not as good as the patients … We used relatively similar time periods, but we relied on
administrative data. … We relied on electronic sources of health information that are held at the research institute.
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psnet.ahrq.gov/node/33721/psn-pdf
November 01, 2011 - VA Surgical
Quality Improvement Program (VASQIP) data was assessed for outcomes.(1) A mobile point of … Simulation
While our initial program plan did not call for the use of simulation, we were persuaded … outcome data to evaluate the overall program. … Each component of the program
builds on the next, so no step can be left out. … The Safety Attitudes Questionnaire: psychometric
properties, benchmarking data, and emerging research
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - data was derived from a database representing 50 health care facilities from 2011 to 2013. … Such rainbow draws are controversial, and no data exists to support the benefit of this practice. … other adverse events, but the outcome could certainly have been different. … Based on CAP data, multiplying this cost with the number of mislabeled specimens, it is believed hospitals … The use of RFID technology may further reduce specimen loss rates by as much as 75%.
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - All of the data are de-identified.
If it ended here, it would already be a great step forward. … On a yearly basis, all of the Matrix outlines are published and distributed to the division in a packet … Yes, some people will not use that information correctly or not use it at all, but the dominant effect … For me, it's this combination of writing and the research that makes that possible. … use of race correction in clinical algorithms.
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - Data on high reliability principles requires scale because it is a collective concept. … In terms of outcome measures, many of the studies I have done rely on a health system being willing to … Another study on medication safety reports on the use of a tool based on HRO principles for reducing … The authors report that use of their HRO-based tool, implemented in 38 Veterans Health Administration … patient falls. 9 Prior research has found that the widespread use of care pathways that standardize