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psnet.ahrq.gov/innovation/clinical-pharmacy-specialists-provide-transitional-care-and-improve-medication-safety
October 30, 2024 - Clinical Pharmacy Specialists Provide Transitional Care and Improve Medication Safety After Discharge … clinic (TCC) led by clinical pharmacy specialists (CPSs) who provide follow-up care to patients after … After the TCC appointment, patients were discharged to their primary care team or specialty provider … Lastly, the TCC expanded to a clinical service provided by ambulatory care CPSs embedded within the patients … Educate the hospital clinical staff on the importance of transitional care and the need to encourage
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - and/or
availability of interventions to reduce hospital readmissions. … be argued that the patient in this case should not have been discharged without a better follow-up
plan … a telemedicine visit utilizing self-taken blood pressure measurements,
augmented by clinical pharmacist-led … Farrell, MD Assistant Professor of Medicine (Clinical) Adjunct Assistant Professor of Family
Medicine … Post-hospital syndrome—an acquired, transient condition of generalized risk.
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - The PT's plan of care focuses on interventions to improve or restore mobility and function. … Each plan is customized to approach the limits of the patient's strength or metabolic capacity. … in a patient's condition, which may indicate or prompt the need for additional medical evaluation. … Developing clinical guidelines (or criteria and triggers for referral) is a recommended approach to optimize … Take-Home Points A PT's plan of care focuses on interventions to improve or restore mobility and
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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/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Oftentimes, the patient or caretaker assumes full responsibility of all patient care postdischarge. … communication with providers via telemedicine to mobile applications that help patients follow a postdischarge plan … Katherine Liang Clinical Informatics UMass Memorial Health Care Medical Student University of Massachusetts … Our study showed that they cannot recount the basic facts of their condition or what happened to them … People come in the hospital with a condition.
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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/node/33584/psn-pdf
March 15, 2025 - hand, comprehend the data, forecast what may happen based on the data, and formulate an
appropriate plan … In a clinical context, maintaining situational awareness requires information
sharing and open dialogue … among clinicians in order to achieve a shared mental model—the "big picture" of
the patient's condition … turn, will need to
respond respectfully, process and comprehend the new information, and devise a plan … condition, but each assumed the other was primarily managing the problem.
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - this instance, the amended laboratory result was recognized prior to discharge and a new management plan … Errors of the assay process are much less common.( 2 ) Many laboratory errors are of no clinical consequence … method of identification.( 6 ) Creating a fail-safe system of communication between two silos, the clinical … patient's condition and reason for ordering the test (pregnancy, sepsis, etc.), further reducing errors … Clinical laboratories should follow strict algorithms for contacting a responsible clinician when communicating
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psnet.ahrq.gov/issue/medical-office-comparative-database-submission-information
February 24, 2021 - (R21/R33 - Clinical Trial Optional). … Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition … December 9, 2015
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings … June 22, 2022
AHRQ Challenge on Innovative Solutions To Update or Re-Create TeamSTEPPS … October 28, 2020
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See More About The Topic
Ambulatory Clinic or
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - 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.
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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/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - A retrospective study of endotracheal or tracheostomy tube blockage and their impact on the patients … in an intensive care unit. … The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. … or developer of the innovation. … Units
Health Care Providers
Health Care Executives and Administrators
View More
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan … recognition and management of ACPO is important to minimize
morbidity and mortality of this serious condition … competence in a wide variety of clinical scenarios. … An institutional culture that encourages communication among all members of the health care team can … condition.
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - present case, the patient required intravenous immunoglobulin (IVIG) to treat her underlying neurologic condition … It requires the establishment of a plan and education for providers and patients to safely reach the … The clinical effectiveness and cost-effectiveness of central venous catheters treated with anti-infective … Wire
August 21, 2005
Implementation of the I-PASS handoff program in diverse clinical … and Poor Communication at Discharge Leads to a PICC without a Plan.
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - must be entered into the EHR so everybody on the team is
aware of them in the event the patient’s condition … • Best practice is to explore individual patient preferences, providing all
options based on their condition … teams will not address acute changes in condition
– Overestimation of CPR success rates
• Hospital … might be the
patient’s preference
• Clinicians should not allow concerns about metrics to color clinical … • Communication among clinical specialties, nursing, and the entire
interprofessional team is critical
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psnet.ahrq.gov/node/49500/psn-pdf
January 01, 2006 - should
target individual providers and parents, medication labeling practices, and broader health care … Physicians’ office personnel, pharmacists, and
all health care providers play an important role in educating … Lastly, requiring pharmacies or drug manufacturers
to prepare a “handout” (or display) at the point … Points
Acetaminophen hepatotoxicity after multiple supratherapeutic doses is a rare and preventable
condition … Always screen for concurrent use of cough/cold preparations containing acetaminophen if you plan
to
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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/866205/psn-pdf
July 10, 2024 - Packing the wound
in this case may have been an appropriate plan to start, but the lack of further intervention … Presumably the patient’s condition improved temporarily with volume expansion but given
the need for … when it became clear that the surgical team was not being sufficiently responsive, and the
patient’s condition … When bleeding is brisk, laboratory results are typically not available fast enough to help guide
clinical … cells in a
1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - of those patients did not understand the next steps after leaving the ED, including what to do if a condition … gets worse or doesn’t improve. … approaches bring together clinicians with the goal of sharing patient information and collaborating on a plan … As usual care resumes, institutions may find that many or all of these examples have the potential to … Director of Clinical Research, Brigham Health Hospital Medicine Unit
Professor of Medicine, Harvard
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - distributing health care goods or services consumed by, or used on patients” and relevant financial … is aware of them in the event the patient’s condition deteriorates. … hands and not address acute changes in condition. … Other clinical skills are certainly important, but these conversations around advance care planning and … the designated health care agent (sometimes also called surrogate, representative, decision-maker, or