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psnet.ahrq.gov/node/49638/psn-pdf
January 01, 2012 - only briefed on the initial respiratory distress and did not have a complete picture of
the child's condition … Yet, if that is all that happened, the next child in this same condition in this same institution will … At the moment of this first transition of care (i.e., the OR to the ICU), the surgeon clearly has the … of a complex patient to formulate the mental model and care plan. … Physician staffing patterns
and clinical outcomes in critically ill patients: a systematic review.
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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/annals-clinical-decision-making-avoiding-cognitive-errors-clinical-decision-making
May 25, 2016 - Commentary
Annals Clinical Decision Making: avoiding cognitive errors in clinical … Annals Clinical Decision Making: avoiding cognitive errors in clinical decision making. … diagnostic process to avoid such errors, including using diagnostic checklists , conferring with teammates or … View More
See More About The Topic
Hospitals
Ambulatory Clinic or … Office
Health Care Providers
Medicine
Nurse Care
View More
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psnet.ahrq.gov/periodic-issue/periodic-issue-375
December 14, 2022 - Operational failures – breakdowns in care processes, such as distractions or situational constraints … Children with complex care needs present unique challenges for both parents and clinical teams. … EHR issues fell into three general areas: information gathering, medical decision-making, and plan implementation … policies and the steps she and her family took to manage her condition. … The condition worsened, signaling failure of non-operative management; following his wishes, he transitioned
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
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. … 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/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/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - that he or she performs. … Our understanding of how burnout influences clinical care is still growing, but it has been associated … and 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. … Systems should clearly designate which physicians should be contacted for particular clinical problems
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Hospital-Acquired Condition Reduction Program (HACRP). Accessed June 28, 2022. … ; 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/50612/psn-pdf
October 30, 2019 - intern night float, who was cross-covering this patient, to come to the bedside to
assess the patient's condition … The signout did
not provide a contingency plan explaining what course of action to take should the patient … resident in the hallway and asked him to assess the
patient and to assist in managing the patient's care … several days and that the family had already decided the patient should be transitioned to comfort care … A randomized trial of nighttime physician staffing in an intensive
care unit.
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psnet.ahrq.gov/issue/staff-care-how-engage-staff-nhs-and-why-it-matters
November 30, 2016 - London, UK: Point of Care Foundation; January 2014. … The well-being of clinical staff is crucial to ensuring safe care delivery. … Copy Citation
Related Resources From the Same Author(s)
Safer Clinical Systems … View More
Related Resources
Why Hospitals Should Fly: The Ultimate Flight Plan … to Patient Safety and Quality Care.
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - , confusion, dyspnea, and/or non-
remitting headache. … Fortunately, the actual source of the patient’s
condition was recognized in time, but heroic interventions … protocols
that have proven to be effective interventions.15,16 A key element in the CMQCC response plan … The strength of
this checklist is that it clearly spells out a plan that avoids missing critical elements … California Maternal Care Quality Collaborative (CMQCC). Accessed November 19, 2021.
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - trigger tools, patient reports, and administrative or claims data. … enrolled in fee-for-service Medicare, in support of CMS
programs that include:
Hospital-Acquired Condition … As another example, the American Society for
Clinical Laboratory Science has proposed a patient safety … /global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-health-care
https://psnet.ahrq.gov … programs to include new metrics focused on diagnostic accuracy and hospital harms, captured as
electronic clinical
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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/periodic-issue/periodic-issue-395
June 28, 2023 - CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition … Clinical decision-making can be influenced by both individual and team factors. … CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition … Positive response strategies included announcing that an error has occurred and the plan for managing … or across settings (e.g., hospital and primary care).
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - They were reviewing the plan of care and discussed the reason for the IVC filter (an unusual intervention … Fang, MD, MPH
Venous thromboembolism (VTE) is a common cardiovascular condition that affects more than … Venous thromboembolism is a condition commonly faced by both inpatient and outpatient clinicians. … to intensive care. … Units
Health Care Providers
Critical Care
Diagnostic Test Interpretation Error
Anticoagulants
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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/periodic-issue/periodic-issue-450
August 28, 2024 - Before large language models (LLM) can be integrated into clinical care, they must be shown to perform … Before large language models (LLM) can be integrated into clinical care, they must be shown to perform … Commentary
Analysis of an academic medical center’s corrective action plan in response … This study evaluates the proposed action plan of an academic medical center following a fatal medication … Despite initial treatment, her condition did not improve as expected.
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
February 01, 2013 - chronic condition. … planning and clinical teaching for trainees. … views about what happened and what didn't happen in the last 24 hours, and their perceptions about the plan … at the bedside, where engaged patients, armed with information about their condition and available services … or the care of loved ones.
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psnet.ahrq.gov/issue/racialethnic-disparities-interhospital-transfer-conditions-mortality-benefit-transfer-among
April 14, 2021 - adherence, and chronic condition control. … Perspectives of emergency clinicians about medical errors resulting in patient harm or … November 30, 2022
Emotional exhaustion among US health care workers before and during … May 19, 2021
Comparison of methods to reduce bias from clinical prediction models of … vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Despite intensive care, the
patient’s condition remained unstable, and he expired several days later … Addressing the patient’s urgent condition relied
on ACLS execution by providers available at the scene … Root causes may include not formulating a plan that anticipates potential consequences,
communication … All clinical providers in these settings should be familiar with ACLS guidelines and
competent in the … unit or the hospital ward, or more unconventional locations, such as the radiology
suite or clinic.