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psnet.ahrq.gov/issue/global-comparators-project-international-comparison-30-day-hospital-mortality-day-week
May 04, 2016 - The weekend effect of worse patient outcomes when admissions or procedures occurred outside of usual … View More
See More About The Topic
Emergency Departments
Operating Room
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
October 01, 2014 - Walks Frequently:
Walks outside the room at least twice a day and inside room at least once every … Walks Frequently
Encourage ambulating outside the room at least bid.
Check skin daily. … Encourage ambulating outside the room at least bid.
No interventions required. … Reports any skin issues to nurse
Turns/repositions patient as ordered
Offers liquids each time in room
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
October 01, 2014 - Walks Frequently:
Walks outside the room at least twice a day and inside room at least once every … Walks Frequently
Encourage ambulating outside the room at least bid.
Check skin daily. … Encourage ambulating outside the room at least bid.
No interventions required. … Reports any skin issues to nurse
Turns/repositions patient as ordered
Offers liquids each time in room
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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - The patient was then taken to the operating room, where he
awaited the arrival of the surgeon. … evaluate and, given complaints of acute neck pain, the patient was transferred to
the local emergency room … Because of this poor
communication, the nurse assumed that the block would be placed in the operating room … requirements, obtaining necessary education, and declining or asking for help with assignments that are
truly outside … Handoff checklists improve the reliability of patient handoffs in the operating room
and postanesthesia
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - The patient was then taken to the operating room, where he awaited the arrival of the surgeon. … evaluate and, given complaints of acute neck pain, the patient was transferred to the local emergency room … Because of this poor communication, the nurse assumed that the block would be placed in the operating room … requirements, obtaining necessary education, and declining or asking for help with assignments that are truly outside … Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia
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www.ahrq.gov/sites/default/files/wysiwyg/topics/hhs_ed_boarding_may30.pdf
May 30, 2023 - The same issue of needed staff also holds true for transfer outside the facility, such as to an inpatient … accommodated by boarding in the
ED, filling up valuable beds, hallways, and even seats in the ED waiting room … more than 70 hours at their hospital, “…we have patients who
unfortunately have died in our waiting room … All the above-described long wait times are entirely outside of the control of the emergency department
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hcup-us.ahrq.gov/db/vars/pointoforiginub04/kidnote.jsp
October 04, 2025 - of this hospital (effective beginning in October 2007) 7 Emergency room (officially discontinued as … (discontinued 7/1/10)
7
Emergency room
8
Court/Law enforcement
8
Court/Law enforcement … (discontinued 7/1/10)
7
Emergency room (discontinued 7/1/10)
8
Court/Law enforcement
8 … 7
Emergency room
8
Court/Law enforcement
8
Court/Law enforcement
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Transfer … this hospital (2007-2010)
6
Born outside this hospital
6
Born outside this hospital (beginning
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
March 05, 2008 - and medication order near misses (five reports), wrong vaccine administered
(four reports), wrong outside … reports in pediatric ambulatory practice
Communications
Error: Child with varicella seated in waiting room … 1,000 patients.24 In another pediatric emergency setting,
22 percent of acetaminophen dose orders were outside … alone may occur in 15 to 22 percent of outpatient encounters.11, 14, 16 Many medication
errors by outside
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hcup-us.ahrq.gov/db/vars/pointoforiginub04/nisnote.jsp
October 04, 2025 - of this hospital (effective beginning in October 2007) 7 Emergency room (officially discontinued as … (discontinued 7/1/10)
7
Emergency room
8
Court/Law enforcement
8
Court/Law enforcement … (discontinued 7/1/10)
7
Emergency room (discontinued 7/1/10)
8
Court/Law enforcement
8 … (Discontinued; effective 1/1/11)
7
Emergency room
8
Court/Law enforcement
8
Court/Law … 7
Emergency room
8
Court/Law enforcement
8
Court/Law enforcement
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Transfer
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
March 05, 2008 - and medication order near misses (five reports), wrong vaccine administered
(four reports), wrong outside … reports in pediatric ambulatory practice
Communications
Error: Child with varicella seated in waiting room … 1,000 patients.24 In another pediatric emergency setting,
22 percent of acetaminophen dose orders were outside … alone may occur in 15 to 22 percent of outpatient encounters.11, 14, 16 Many medication
errors by outside
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - She was taken to the operating room and underwent an uneventful change of the
ECMO circuit. … it took the perfusionist almost 30 minutes to
see the patient after the patient left the operating room … The perfusionist immediately realized that the
oxygenator was filled with room air. … During ECMO, blood is drained from the patient's vascular system, circulated outside the body by a
mechanical … In this Case, the patient experienced an adverse event during transport on ECMO from the operating room
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - She was taken to the operating room and underwent an uneventful change of the ECMO circuit. … it took the perfusionist almost 30 minutes to see the patient after the patient left the operating room … The perfusionist immediately realized that the oxygenator was filled with room air. … During ECMO, blood is drained from the patient's vascular system, circulated outside the body by a mechanical … In this Case, the patient experienced an adverse event during transport on ECMO from the operating room
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www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-preventing-cauti-transcript.html
November 01, 2015 - If the patient has more IV pumps than there are people in the room, they're probably ICU caliber. … you don't want to add something else that they have to worry about holding on to if they're trying to ambulate … We also have to remember that outside of the ICU setting and sometimes in the ICU setting, that strict … Next, a hip fracture who's going to the operating room, eventually. … They are in a patient bed, in a typical looking patient care room.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-transcript.html
December 01, 2017 - If the patient has more IV pumps than there are people in the room, they're probably ICU caliber. … you don't want to add something else that they have to worry about holding on to if they're trying to ambulate … We also have to remember that outside of the ICU setting and sometimes in the ICU setting, that strict … Next, a hip fracture who's going to the operating room, eventually. … They are in a patient bed, in a typical looking patient care room.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/No_More_CAUTI_Preventing_CAUTI_transcript.docx
May 05, 2015 - If the patient has more IV pumps than there are people in the room, they're probably ICU caliber. … you don't want to add something else that they have to worry about holding on to if they're trying to ambulate … We also have to remember that outside of the ICU setting and sometimes in the ICU setting, that strict … Next, a hip fracture who's going to the operating room, eventually. … They are in a patient bed, in a typical looking patient care room.
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case6.html
November 01, 2014 - Emergency room. … The final two live dry runs included outside vendors, such as the ambulance services that transported … These challenges also required the use of additional tools outside of the Lean toolbox. … These challenges also required the use of additional tools outside of the Lean toolbox. … Where you need to pull in people from the outside, learn and be constant learners.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Lavelle_33.pdf
March 12, 2008 - RN: Patient in wheelchair to cart in exam room; staff notify physician that patient with chest
pain … Assure that personnel are waiting at door to escort EMS to patient’s room. … patients with chest pain or allergic
reactions to larger procedure rooms
• Leave code cart in hallway outside … exam room
• Crowd control: ancillary staff (pharmacist, lab,
extra CMAs, nurses) stay outside of … room until
invited in
Staff uncomfortable with ECG rhythms
• Review dangerous rhythms for clinic
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
October 01, 2014 - Walks Frequently:
Walks outside the room at least twice a day and inside room at least once every … Walks Frequently
Encourage ambulating outside the room at least bid.
Check skin daily. … Encourage ambulating outside the room at least bid.
No interventions required. … Reports any skin issues to nurse
Turns/repositions patient as ordered
Offers liquids each time in room
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
October 01, 2014 - Walks Frequently:
Walks outside the room at least twice a day and inside room at least once every … Walks Frequently
Encourage ambulating outside the room at least bid.
Check skin daily. … Encourage ambulating outside the room at least bid.
No interventions required. … Reports any skin issues to nurse
Turns/repositions patient as ordered
Offers liquids each time in room
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psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - "I don't know how to get there except to go outside and through the front door," a colleague answered … So the senior resident and intern ran down numerous flights of stairs, outside the front of the hospital … At this point, a staff nurse on the psychiatry floor came into the room, recognized the patient, and … emergency department would not only encompass what is generally thought of as a hospital's emergency room … December 16, 2020
Patient safety in the cardiac operating room: human factors and teamwork