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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - aware of these events from various sources, we have mechanisms to ensure these are reported to the appropriate … determine the best place to access care, for example emergency or urgent or next day appointments that are appropriate … Amy Helwig: I think it's appropriate to make performance data publicly available.
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psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - The alert emphasized the importance of educating physicians on appropriate test utilization and standardizing
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psnet.ahrq.gov/issue/surgical-skill-and-complication-rates-after-bariatric-surgery
August 02, 2015 - November 17, 2010
The impact of the 80-hour work week on appropriate resident case coverage
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psnet.ahrq.gov/issue/validity-selected-ahrq-patient-safety-indicators-based-va-national-surgical-quality
July 14, 2009 - Publicly available hospital comparison web sites: determination of useful, valid, and appropriate
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psnet.ahrq.gov/issue/computerized-triggers-big-data-detect-delays-follow-chest-imaging-results
March 19, 2018 - December 3, 2014
Decoding laboratory test names: a major challenge to appropriate patient
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Through a just culture lens, the LPN did require appropriate coaching and additional training. … Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - Instead, you can use the informal consultation to encourage the colleague to seek appropriate help. … Instead, encourage the colleague to seek appropriate help.
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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - complications; (2) failure to relay information to the care team, and (3) failure to react in a timely and appropriate … If you’re not setting up your system to interrupt only when it’s appropriate, the alarms cause more harm … George, as chief quality officer, found that if you had appropriate ordering of telemetry, you could
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - of patient care to clean hands, and they simply could not wash their hands with soap and water in an appropriate … cannot tell if or when people are using the alcohol-based hand rub, if it is appropriately used at the appropriate … Or, "You could have waited during the course of care to perform hand hygiene at a much more appropriate … completely agree that patients should have the right to benefit from health care workers practicing appropriate
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psnet.ahrq.gov/node/73186/psn-pdf
April 28, 2021 - Inappropriate dosing of direct oral anticoagulants in
patients with atrial fibrillation.
April 28, 2021
Sugrue A, Sanborn D, Amin M, et al. Inappropriate dosing of direct oral anticoagulants in patients with atrial
fibrillation. Am J Cardiol. 2020;144:52-59. doi:10.1016/j.amjcard.2020.12.062.
https://psnet.ahrq.go…
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - agreement on how to standardize practices, procedures, and products; shifting of responsibilities where appropriate
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psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - TSOACs may also not be appropriate for patients who have a very high bleeding risk, such as in the situation … For example, obtaining a thrombin time may be appropriate to determine whether there is residual dabigatran
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - Less effort has been committed to justification—ensuring that the test is appropriate. … The former role requires that requested examinations are clinically appropriate and the potential benefits … You asked about what clever solutions will lead to more appropriate use of imaging. … There's work in decision support tools to bring some of what we know about appropriate and inappropriate
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - require at least two large-bore intravenous catheters, with 22-gauge catheters typically providing appropriate … catheters during complex pediatric surgical procedures should incorporate the following considerations:
Appropriate
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - All of the orchestra members must be clear on their roles and ready to play at the appropriate times. … than the implications of recognizing the severity of the situation and not being able to mobilize an appropriate
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psnet.ahrq.gov/node/48181/psn-pdf
August 07, 2019 - Managing the risks of direct oral anticoagulants.
August 7, 2019
Sentinel Event Alert. July 30, 2019;(61):1-5.
https://psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral
anticoagulants (DOACs) require less…
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - the image, processing the image, interpreting the findings, determining follow-up care, and selecting appropriate … While that can result in more false positives, this approach may be appropriate when the alternative … However, appropriate incorporation of AI has the potential to alleviate some of the workflow burden experienced
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - medical care such as self-extubation.( 24 ) Bedrails may be considered a restraint and are usually not an appropriate … For this patient, continuous observation likely was appropriate. … rounding schedule: assist to bathroom, assist to commode, or provide bedpan Ambulatory aid at bedside if appropriate
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - considered to have delirium until proven otherwise.( 11 ) The diagnosis of "senile dementia" is not appropriate … Cognitive assessment at admission and appropriate use of collateral information from the patient's daughter
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - If it is deemed appropriate to hold all new admissions, alternative solutions must be offered to care … possible that it was unrelated to the staffing—the case highlights the tensions involved in determining appropriate … An appropriate leadership intervention would have been to validate the staff nurse's concerns and develop