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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Determine which events should not go through RCA
Blameworthy events that are not appropriate for RCA2 … Use appropriate tools and identify viable corrective actions
RCA2 tools (e.g., interviewing techniques … implementation and impact on outcomes, and considering the use of abbreviated incident review approaches when appropriate
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - available either in print or digitally, ideally provide patients with disease-specific information appropriate … conversation going Point to the screen; highlight the discussed data; print out when appropriate … Analysis
July 1, 2008
WebM&M Cases
Delay in Appropriate
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - Many organizations have elevated the safety officer to an executive-level position, and I think that's appropriate … that are going to show up as alerts and so forth, the patient safety officer may need to meet with the appropriate … Reliable team interaction should focus on improving understanding of communication, situational awareness, appropriate … Involving physician champions on appropriate projects from the start is very helpful. … Organizations need to develop appropriate safety indicators to gauge their progress.
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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - Reliable team interaction should focus on improving understanding of communication, situational awareness, appropriate … Involving physician champions on appropriate projects from the start is very helpful. … Organizations need to develop appropriate safety indicators to gauge their progress. … Many organizations have elevated the safety officer to an executive-level position, and I think that's appropriate … that are going to show up as alerts and so forth, the patient safety officer may need to meet with the appropriate
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - overuse.( 6 ) Since that time, although significant improvements have been made to address underuse of appropriate … As we begin to develop a critical mass of early adopters of appropriate use, the next step is to cut … reimbursement for double scans, thereby aligning incentives to provide appropriate care. … people examine their own patterns of health care use and begin to ask questions about whether it is appropriate
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - The transcribed order for "40 mg vitamin K IV now" was rationalized as appropriate rather than confirmed … Appropriate safety procedures such as warnings, limiting medication amounts, special labeling and packaging
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psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - Most of these recommendations are also appropriate for ambulatory care and are consistent with our root … ensure that medications and related supplies are clearly labeled and stocked, that staff members receive appropriate
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Both patients had patient identifier wrist bands and were consented for their appropriate procedures. … Conversing with the patient using appropriate identifiers acts as a second check to ensure that the right … arrives directly to the OR, the handoff between the sending and receiving nurses is critical to ensure appropriate
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - utilize them. 6 The first systematic review of organizational strategies and policies designed to ensure appropriate … clinically focused care delivery model that includes collaboration with referring providers to select the appropriate … Take-Home Points Verbal orders are appropriate in certain settings, but improved compliance with best
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Outpatient referral to a pediatric subspecialist often takes weeks or months and is not an appropriate … minutes thereafter. 10,11 A stimulated cortisol level via immunoassay of at least 18 ug/dl indicates an appropriate … should be started on maintenance doses of glucocorticoids and mineralocorticoids and educated about appropriate
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - professional and educational development in the context of a trainee's experience of providing safe and appropriate … not occur ( Figure ).( 8,9 )
Finding this balance requires agency on the part of the learner and an appropriate … responsibilities and hence a graded decrease in supervision.( 13,14 ) Although this feels pedagogically appropriate … This cognitive apprenticeship model can offer trainees appropriate autonomy while ensuring patient safety
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psnet.ahrq.gov/issue/towards-safer-transitions-curriculum-teach-and-assess-hospital-hospice-handoffs
March 20, 2024 - April 26, 2023
TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - While taking responsibility and initially informing the wife of a problem was a positive and appropriate … If an offer of compensation is appropriate, possible liens issued from the US Centers for Medicare & … important for fully understanding the consequences of the patient’s death and therefore determining appropriate
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psnet.ahrq.gov/issue/safe-practices-reduce-cpoe-alert-fatigue-through-monitoring-analysis-and-optimization
February 17, 2021 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate
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psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards
February 03, 2021 - December 18, 2013
Appropriate prescribing of medications: an eight-step approach.
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psnet.ahrq.gov/issue/pain-assessment-and-management-standards-hospitals
September 11, 2019 - April 16, 2018
Safer and more appropriate opioid prescribing: a large healthcare system's
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psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across-providers
September 25, 2019 - March 13, 2019
Actions Needed to Help Ensure Appropriate Medication Continuation and
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - vulnerabilities that are addressed—to greater or lesser degrees—by CPOE:
Ordering: the clinician must select the appropriate … Dispensing: the pharmacist must check for drug–drug interactions and allergies, then release the
appropriate
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Therefore, it may be more appropriate, effective, and ethical to directly link specific risk factors … Review and (where appropriate) discontinuation of "culprit" medications associated with increased risk … Early access to advice, mobility aids, and (where appropriate) exercise from physiotherapists.
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - patients in one study.( 10 ) Strategies such as physician reminders to review whether a catheter is still appropriate … Practices Advisory Committee (HICPAC) guidelines, first published in 1981, summarize recommendations for appropriate … The appropriate components for a bundle and effectiveness of these "all or none" strategies are not yet … For many patient safety problems, that type of applied epidemiological approach is appropriate: falls … These types of things are so rare that approaching them epidemiologically may not be as appropriate as