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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - intrahospital transport
Case: Moving Pains
A 90-year-old woman, whose son was a prominent non-clinical … Case (cont.): Moving Pains
Over the next hour, the patient’s condition continued to worsen. … Hospital did have system for assessing and communicating a patient’s clinical stability, but assessment … Does the assessment take into account the possibility of decline in clinical condition and the need for … Are the transporters qualified or adequately trained for this?
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - The patient was
urgently transferred to the intensive care unit (ICU), where repeat labs showed a sodium … Any condition that reduces a patient's access to free water can unmask nephrogenic diabetes
https:// … 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 reliance
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - We know that one of the primary drivers
of unsafe care or unfortunate outcomes is communication. … Because of that, the focus of the clinical conditions
bundles has expanded. … It is challenging when people cannot access care or pay for care. … because they may be working multiple jobs or do
not have transportation to receive care. … There often is very little way to tie
someone's outcome or mental health condition back to a pregnancy
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psnet.ahrq.gov/node/49470/psn-pdf
December 01, 2004 - 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/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - facilities should implement obstetric hemorrhage risk
assessment, manage and treat iron deficiency anemia, plan … anytime their condition changes.7, 8
• The patient’s hemorrhage risk should be embedded in the EHR, … rate
Systolic >155 or <80 mm Hg
Diastolic >105 or <45 mm Hg
Blood pressure
Altered mental status
Based … continuously evaluate the patient’s hemorrhage risk
throughout the labor and postpartum processes, and plan … A systematic review of the relationship between blood loss and clinical signs.
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psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
June 14, 2017 - Med Care. 2016;54(12):1105-1111. … Establishing hospital quality or payment based on unvalidated metrics has consequences for patient safety … June 14, 2017
Potential harms resulting from patient–clinician real-time clinical encounters … March 12, 2025
Clinical communities at Johns Hopkins Medicine: an emerging approach to … 7, 2020
Changes in hospital safety following penalties in the US Hospital Acquired Condition
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psnet.ahrq.gov/issue/adverse-events-toolkit-clinical-guidance-identifying-harm
July 26, 2023 - Tools/Toolkit
Adverse Events Toolkit: Clinical Guidance for Identifying Harm … Citation Text:
Adverse Events Toolkit: Clinical Guidance for Identifying Harm Maxwell A. … July 26, 2023
Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose … August 9, 2017
National Action Plan for Adverse Drug Event Prevention. … September 10, 2014
Health IT Patient Safety Action and Surveillance Plan.
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - 15K or 25K/mm3, hemoglobin <13.5 or 11 g/dL, sodium
<135 mEq/L, creatinine >1.6 mg/dL, glucose >180 … that he or she performs. … Our understanding of how burnout influences clinical care is still
growing, but it has been associated … no surgeon should consider it appropriate to abandon a patient who potentially has such an urgent
condition … without ensuring an alternate plan for the management of that condition.
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Finally, in phase 4, the whole team (referring
and receiving) agrees on a patient plan and contingencies … mismatch (e.g., a different condition or diagnosis from what was handed over), or
documentation mismatches … technology transfer, information transfer using checklist and standardized
communication, and a joint plan … The long-term challenge is to maintain a reliable system in ever increasingly busy clinical settings. … Failures in transition: learning from incidents
relating to clinical handover in acute care.
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - We develop or
maintain measures ourselves or utilize measures developed by other “measure stewards” … many hospital programs
(such as the Hospital Readmission Reduction Program, the Hospital-Acquired Condition … Patient’s
conditions were more complicated; many patients stayed on ventilators or in intensive care … information and to create a lifelong learning cycle that ties to clinical guidelines and to clinical … Can
we effectively look at data by race, or ethnicity, or language, or many other factors?
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - balance, independence and objectivity in all its CME activities to promote improvements in health care … 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 … It may well have been that this patient could have had a favorable
result with this management plan. … In this context,
the lack of a primary care physician to coordinate post-discharge care may have contributed
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psnet.ahrq.gov/node/49647/psn-pdf
February 01, 2012 - this instance, the amended laboratory result was recognized prior to discharge and a new management
plan … However, approximately 30% of amended laboratory values do lead to a change in patient
care (3,4), as … Despite these challenges, there are few, if any, standard-of-care guidelines to assist hospitals
in … patient's condition and reason for ordering the test (pregnancy, sepsis, etc.), further reducing errors … Problems in laboratory testing in
primary care. JAMA. 1996;275:635-639. [go to PubMed]
3.
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - 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. … 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.
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Included within INTERACT are educational
trainings for providers as well as clinical and education tools … stop and watch” early warning tool, and templates for progress notes and documenting acute
changes in condition … This will inform a plan to ensure that all
nursing home staff understand any workflow adjustments. … were critical to success:
Funding is required to support the inclusion of a dedicated APRN on the clinical … staff across the
nursing home of roles and responsibilities
The establishment and communication of a plan
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Pertinent to the case being discussed, there have been no clinical trials that have compared warfarin … 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/issue/not-just-depression-she-seemed-trapped-downward-mental-health-spiral-real-cause-was-profound
March 03, 2021 - the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition … May 28, 2014
Misdiagnosis is more common than drug errors or wrong-site surgery. … December 5, 2012
View More
See More About The Topic
Ambulatory Clinic or … Office
Physicians
Patients
Mental Health Care (Psychiatry and Clinical Psychology)
Neurosurgery
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - The plan was for him to continue to be weaned from the ventilator and receive physical and occupational … Diagnoses, Comorbidities, and Complications Admission, Discharge, & Expiration Complexity of patient condition … Supplemental Items include condition-specific data collection with the goal to increase standardization … April 30, 2014
Treatment patterns and clinical outcomes after the introduction of the … Cases
Lost in Sign Out and Documentation
April 1, 2016
Clinical
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psnet.ahrq.gov/issue/standardise-educate-harmonise-commissioning-conditions-safer-surgery
August 02, 2023 - Examining risks in surgical care such as deviation in practice, this report outlines strategies to … improve outcomes, including better adoption of care standards, determining organizational safety policies … April 14, 2021
Review into the Quality of Care and Treatment Provided by 14 Hospital … August 7, 2013
Digital Clinical Safety Strategy
October 20, 2021 … April 20, 2016
Rules and guidelines in clinical practice: a qualitative study in operating
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psnet.ahrq.gov/issue/daily-plan-including-patients-safetys-sake
March 13, 2013 - The Daily Plan®: Including patients for safety's sake. … Patients felt the daily plan improved their understanding of their care and helped them identify discrepancies … in the care plan. … The Daily Plan®: Including patients for safety's sake. … January 18, 2023
Effective followership: a standardized algorithm to resolve clinical
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - There are no federal or state requirements for physicians or
advanced practitioners to be onsite in … vocational nurse (LPN or LVN). … have a Quality Assurance
Performance Improvement (QAPI) plan; this plan must outline how the facility … The program resources are free for clinical use at http://interact.fau.edu/. … ; (ii) managing some changes in condition without transfer when safe and
feasible (was our patient unstable