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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - The report noted that a biopsy should not be delayed if a
“suspicious mass” is present on physical exam … It is unknown if an earlier diagnosis would have
affected the outcome of this aggressive malignancy. … In its guidelines, the American College of Radiology notes that “the use of a probably
benign assessment … Impact of patient navigation on timely cancer care: the
Patient Navigation Research Program. … BI-RADS 3: Current and Future Use of
Probably Benign.
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psnet.ahrq.gov/node/49424/psn-pdf
November 01, 2003 - The anesthesiologists were short-staffed and also covering the operating rooms on a different
floor, … outcome. … If data such as the frequency of medication errors,
incidence of wound infections, or patient satisfaction … The use of high-
fidelity patient simulators for training health care professionals has increased in … Neurosurgical trauma call: use
of a mathematical simulation program to define manpower needs.
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psnet.ahrq.gov/perspective/weekend-effect
April 01, 2008 - vary depending on the time of day or day of the week. … This Annual Perspective will summarize the state of research on the weekend effect and highlight advances … A seminal 2001 study was among the first to document the weekend effect on a large scale. … Patients who present to the hospital on weekends may have a condition of greater severity or multiple … Most studies of the weekend effect rely on hospital-based administrative data .
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - part on the needs and
resources of a particular health system or practice. … the number of languages a health system can staff efficiently and time constraints on staff
availability … data on satisfaction with communication comparing telephonic and in-person interpretation are mixed … Impact of patient language proficiency and interpreter service use on the quality
of psychiatric care … A comparison of the influence of hospital-
trained, ad hoc, and telephone interpreters on perceived
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psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - On hospital day 3, the patient had a discussion alone with a hospitalist, in which the patient was documented … likely consequences of each choice, use reasoning to decide among the options, and be able to express … Predicting outcome in older hospital patients with delirium: a systematic literature review. … The U-ARE Protocol: A Pragmatic Approach to Decisional Capacity Assessment for Clinical Research. … August 13, 2014
Using a claims data-based sentinel system to improve compliance with
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - way for further research on healthcare team dynamics and the impact on patient safety. … The Joint Commission. Sentinel Event Data 2022 Annual Review. The Joint Commission; 2023. … groups of students or colleagues on the use of TeamSTEPPS. … I think that the outcome is wonderful, and a few of my favorite additions are the patient safety videos … use the curriculum.
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - There are also a few who are impaired due to drug and alcohol use. … outcome. … in communication.( 10 ) While there is a growing body of research that supports the benefits of strong … Phase three of our research is focusing on factors that cause bad behaviors to occur. … The scope of the outcome was varied.
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - to be
a long path before I could generate a lot of research papers doing simulation alone. … RW: Looking back over the last 10 to 20 years of research, how would you summarize what the research … use of complex medical technology before use. … This is the most important aspect of a simulation
experience; reflecting on what you did is a crucial … But there will be other opportunities—especially the simulation of big data at the system levels.
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - , because their roles are different.( 4 ) Data from the multinational RN4Cast study found a two-fold … Based on data from more than 400,000 patients and surveys of 26,000 nurses across Europe, we found that … assessment of the impact on patient care.( 14 ) By the time there was sufficient data and analysis to … We've added a lot of management levels and we have a whole bureaucracy of safety people, but our data … safety of the clinical environment, and we're superimposing these interventions on top of a defective
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - We centered on the use of pulse oximetry because you can get a lot of valuable information from a single … A lot of patients in the hospital are on opioids. … use it as a tool. … a distraction and change of attention from the task on hand. … Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - 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 … And providers will
be trained to do it, perhaps best via simulation.(9,10)
The data elements of a good … Use of strategies from high-reliability organisations to the patient hand-off by resident
physicians … Agency for Healthcare
Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/issue/national-statutory-reporting-not-even-ticking-boxes-quality-learning-deaths-reporting-quality
February 22, 2023 - statutes, a small minority did not submit any data. … document analysis of the first year of a countrywide patient safety programme. … November 9, 2022
The impact of drug error reduction software on preventing harmful adverse … October 21, 2020
Association of electronic health record use above meaningful use thresholds … administrative data from the United States.
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - So they would rather err on the
side of alerting. The EHR has a similar issue. … The
analogy I use for this is getting on a plane where the pilot hasn't been through the simulator. … The meaningful use
program has a lot of administrative overhead. … That was a theme of
my research in thinking about this for a year: the unanticipated consequences of … I'm very
enthusiastic about the outcome.
It's a voluntary, public–private partnership.
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psnet.ahrq.gov/node/49780/psn-pdf
January 01, 2017 - Based on
the report, she took the patient to the operating room for treatment of a presumed recurrent … in the digital
era may have affected the outcome of this patient's surgery. … Whatever the merits of the decision, this particular case had a problematic outcome: after an
uncomplicated … of
PACS, a radiologist typically reviewed images on the same day they were acquired. … Research and Quality (AHRQ), U.S.
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psnet.ahrq.gov/issue/surgical-safety-and-hospital-volume-across-wide-range-interventions
April 04, 2011 - Classic research has demonstrated a link between increased surgical volume and improved patient outcomes … However, this study finds that the volume–outcome relationship is limited to a few specific surgeries … users of coded health data. … June 19, 2019
A comparative effectiveness analysis of the implementation of surgical … environments: a randomized trial of the "preoperative warm-up" effect.
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - anaphylaxis, resulting in an excellent patient outcome. … Condom use may also be a risk factor. … If medical personnel are unclear about the allergen content of a latex product, exclusion from use is … The Pennsylvania Patient Safety Authority (PPSA) undertook such research and published the results on … Impact of repeated surgical procedures on the incidence and prevalence of latex allergy: a prospective
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - use incentive program. … Both of those have a significant impact on health. … Institute of Medicine’s 2000 publication To Err Is Human summarized research on the impact of medical … research and application focused on hospitals. … A bibliometric analysis of 20 years of research.
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - The Case
A 55-year-old woman with a history of type 2 diabetes on metformin presented to the emergency … possible diagnostic
errors will capture only a fraction of events (11), organizations must rely on … the intended outcome (i.e., earlier diagnosis with
avoidance of human and capital costs associated … In addition, the commentary
does not include information regarding investigational or off-label use … This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare
Research
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - CC: I think that communicating and focusing on the use of evidence to improve practice is hard-wired … , where you use a mix of both process and outcome measures such as those found in AHRQ's National Healthcare … reflects a different kind of translational research: the translation not of basic research discoveries … military (including the use of the NATO alphabet; alpha for A, bravo for B, etc.) and the take-out restaurant … January 9, 2024
Physician liability in the age of data reliance and errors.
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - One area that has seen significant advances is public reporting of quality data, at a federal level ( … A great example of this is the issue of the Meaningful Use standard for discharge summaries. … Clinicians need to start beating on the vendors to make this stuff easier to use. … shoved the outcome downward. … As the shared hospital medical record and individual data-gathering gadgets start to build a cloud of