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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - Computerized clinical decision
support mechanisms, such as order sets, should be used to help users … can include similar
details if the healthcare provider indicates the condition being treated, the acuity … of that condition, and the
patient’s current weight and renal function. … EHR-generated instructions regarding the patient’s post-discharge plan of care. … Patient education should not be provided until after the discharge plan has been finalized to
prevent
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - The plan was for the patient to follow up with his primary care physician in 2 weeks. … plan, including any pending test results. … or forwarded to his primary care physician. … However, because, more often than not, microbiology TPADs do not alter the care plan, physicians have … Improving communication between the discharging physician and the provider or care team assuming care
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - (e.g., transfer to the intensive care unit), inefficiencies in care, and delays in
diagnosis or treatment … Handovers are critically important for establishing a shared
mental model about the patient's condition … The handover provides information
about the patients' clinical course and condition, as well as what … clinical status). … Have a formal plan for handover at change of shift and change of service
2.
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - This objective is achieved by formulating a management plan that takes into consideration severity of … in management of her condition, such as a high-risk specialist. … dysfunction as well; in these patients, it may be difficult to distinguish a worsening underlying medical condition … All facilities providing care for obstetric or postpartum patients should also develop mechanisms that … Providers
Risk Managers
Obstetrics
Clinical Misdiagnosis
View More
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - This includes information about the nature of the patient’s medical condition and prognosis, as well … professionals the plan of care based on the patient’s decision. … include the basis for the patient’s decision, the patient’s capacity to understand and communicate, the plan … This practice would provide an additional safety measure to ensure that important clinical decisions … practices: a randomized clinical trial.
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - managing the patient was uncertain as to whether
the psychosis was due to a “primary” psychiatric condition … (e.g.,
schizophreniform disorder, schizophrenia) or a systemic medical condition,
so two consultations … • This patient could have had a favorable result with this management plan, but we
will never know … predominant
presentation of psychosis reduced the likelihood of the patient seeking primary
medical care … • In this context, the lack of a primary care physician to coordinate post-discharge
care may have
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - discharge Understand the provider's role in reducing adverse events at discharge Create an action plan … is required so that when patients need to be closely followed after discharge, either because their condition … Lastly, they need to have a back-up plan for when things go wrong. … care organization. … Dictated versus database-generated discharge summaries: a randomized clinical trial.
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - : “Thus, clinicians facing patients at risk of [acute compartment syndrome] must choose a treatment plan … E ducate the patient and family in plain language about the patient’s condition, the discharge process … A ssess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s … care to the patient and family and use teach back. … In a study of 30,727 members of a commercial health plan, patients discharged after hospitalization who
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - condition (i.e., type 1 diabetes) is crucial. … be able to diagnose diabetic ketoacidosis (DKA) early, as it is a life-threatening yet preventable condition … for diabetes due to lack of access to care or the high costs of insulin in the United States. 2 … about management of their sick days, how to trouble-shoot pump malfunction, and how to develop a backup plan … Do professional interpreters improve clinical care for patients with limited English proficiency?
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - due to sudden changes in clinical condition) of intrahospital transport for patients
in acute medical … Over the next hour, her condition continued
to worsen. … What are the contingency plans if the patient's condition changes en
route? … School of Nursing Clinical Nurse Specialist, Adult Critical Care, UCSF Medical Center
https://psnet.ahrq.gov … Does the assessment take into account the possibility of decline in clinical condition and the need
-
psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - postpartum and can similarly lead to
failure to recognize clinical deterioration or serious illness … condition or do not receive the right care quickly
enough in an emergency. … Maternal sepsis is defined as a life-threatening condition with organ dysfunction resulting from infection … for implementation, including assessing
potential strategies for fit, developing an implementation plan … HRSA)
funds multiple initiatives to improve maternal health outcomes34 and has developed a strategic plan
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psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
October 26, 2022 - Any condition that reduces a patient's access to free water can unmask nephrogenic diabetes insipidus … Improving Diagnosis in Health Care. … cognitive challenges that are not required at the time (e.g., planning alternative diagnosis/treatment plan … should the initial plan prove ineffective or incorrect) Giving feedback Simulation Reducing … (Psychiatry and Clinical Psychology)
Clinical Misdiagnosis
Cognitive Errors ("Mistakes")
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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - and collaborate with the clinical care team to recommend a response. … The condition often occurs with hospital or community-acquired pneumonia, bloodstream infections, and … and other alerts, remote nurses are better equipped to respond to alerts, assess the patient’s condition … Crit Care Med. 2023;51(4):431-444. … or developer of the innovation.
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - By clinical background, I am an internal medicine hospitalist. … Instead of a causal factor, we'll say condition/contributing factor. … I think there are a lot of ways to do that, with the National Action Plan being one of them. … This approach to patient safety is referred to as Safety-I , which defines safety as a condition where … Patient safety learning laboratory looks to enhance clinical communication.
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - condition (i.e., type 1 diabetes) is crucial. … be able to diagnose diabetic ketoacidosis (DKA) early, as it is a life-
threatening yet preventable condition … for
diabetes due to lack of access to care or the high costs of insulin in the United States.2
Even … management of their sick
days, how to trouble-shoot pump malfunction, and how to develop a backup plan … Do professional interpreters improve clinical care for
patients with limited English proficiency?
-
psnet.ahrq.gov/node/49585/psn-pdf
May 01, 2009 - Despite the patient's deteriorating clinical
condition, the patient's worsening level of consciousness … Her condition did not significantly
improve, and she eventually died 2 weeks later. … Incorporating their contribution into the plan of care is strongly recommended.
James L. … Delirium in the intensive care unit:
occurrence and clinical course in older patients. … hospital care.
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - postpartum and can similarly lead to failure to recognize clinical deterioration or serious illness. … Thus, patients are at risk for underuse or omission if they do not receive the right care for their condition … or do not receive the right care quickly enough in an emergency. … for implementation, including assessing potential strategies for fit, developing an implementation plan … funds multiple initiatives to improve maternal health outcomes 34 and has developed a strategic plan
-
psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - due to sudden changes in clinical condition) of intrahospital transport for patients in acute medical … Over the next hour, her condition continued to worsen. … What are the contingency plans if the patient's condition changes en route? … School of Nursing Clinical Nurse Specialist, Adult Critical Care, UCSF Medical Center Robert M. … Does the assessment take into account the possibility of decline in clinical condition and the need for
-
psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - evaluation , requires physicians to ask what gaps might exist in their understanding of the patient's condition … she has the knowledge and skill to care for a condition outside his or her primary scope of practice … health plan. … care
October 2, 2019
Blink or think: can further reflection improve initial diagnostic … November 28, 2012
How teams work—or don’t—in primary care: a field study on internal
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - ; an update on the patient’s current condition; a
review of medications; and discussions of the ongoing … care plan, including any challenges. … They found that the majority of transition of care breakdowns involved discharge
communication or coordination … Identify one or two individuals who can serve as the primary point (or points) of contact at each site … Identify individuals to serve in key innovation clinical roles.