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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - decision support when there is diagnostic uncertainty or complexity. … Clinical Decision Support and Increased Adherence with Evidence-based Care
CDS has the potential to … This may include, but is not limited to, notifications, alerts and reminders, condition-specific order … in oncology care increased clinical practice guideline use and concordance, improved care process measures … Health Information Technology Patient Safety Action & Surveillance Plan. July 2, 2013.
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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/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - 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 … or diarrhea). … competence in a wide variety of clinical scenarios. … condition.
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - systems of care do not provide adequate coverage or offer necessary resources for urgent clinical situations … psychiatric inpatient facilities resist admitting any new patient who “may have” underlying medical condition … An EMC is “a medical condition manifesting itself by acute symptoms of sufficient severity (including … to emergency departments (EDs), even when the risk of a contributing medical condition or an alcohol … and Clinical Psychology)
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - , the patient deteriorated, developing respiratory failure and requiring transfer to
the intensive care … If the answer is yes, consider withholding the steroids, empirically
treating the other condition, or … pursuing more aggressive diagnostic testing to rule out the condition. … She sees you, her primary care
physician, 3.5 weeks after symptoms began. … Patients on either of these two
regimens were more likely to achieve a clinical remission of disease
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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/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was … However, these clinical signs often fail to detect awareness. … 24 Finally, it is important to recognize that some cases of awareness are intended, as part of the plan … of care. … simultaneously impaired by opioid pain medications, the patient may not remember that the anesthetic plan
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psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - The patient was discharged, but his condition worsened over the following week, with increasing back … intradural tumors, the dura is opened intentionally, and reapproximating via suturing is the intended plan … fluid (CSF) leaks through the dural tear into the surrounding tissue, forming a fibrous capsule, the condition … of care to non-conservative therapy should begin. … Take-Home Points
40
The best offense is a good defense and avoidance of a durotomy, if not in the plan
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psnet.ahrq.gov/issue/pay-performance-and-patient-safety-acute-care-systematic-review
October 09, 2024 - Pay-for-performance (P4P) policies and programs (such as the Hospital-Acquired Condition [HAC] Reduction … Interview
In Conversation With...Amy Helwig about Health Plan … July 10, 2024
Perspectives on Safety
Health Plan … Improving Diagnostic Safety and Quality
April 26, 2023
Clinical … November 7, 2012
Computerized physician order entry with clinical decision support in
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - Encounter and claims data indicate if a health plan member is seen in a clinic, a hospital, or even … matter
where or how frequently it was refilled. … that specializes primarily in young adults or a
plan with a large number of pediatric members. … the emergency department or urgent care. … emergency
or urgent or next day appointments that are appropriate depending on their condition.
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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/node/50928/psn-pdf
February 21, 2020 - decision support when there is diagnostic uncertainty
or complexity. … Clinical Decision Support and Increased Adherence with
Evidence-based Care
CDS has the potential to … This may include, but is not limited to,
notifications, alerts and reminders, condition-specific order … oncology care increased clinical practice guideline
https://psnet.ahrq.gov/issue/development-and-implementation-subcutaneous-insulin-pen-label-bar-code-scanning-protocol … Health Information Technology
Patient Safety Action & Surveillance Plan. July 2, 2013.
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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/node/33604/psn-pdf
December 15, 2024 - fact that the five rights must be individualized, as they are
affected by the patient's age, medical condition … safety for each individual
patient
Individual consideration of "five rights" in light of
patient condition … transitions
Coordinate medication
management across care
transitions; assist with care
coordination … from
medication list at transitions in care, which are
prone to error. … Clinical trials are another area in which pharmacist leadership in
designing safe protocols is critical
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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/node/49822/psn-pdf
March 01, 2018 - She
spiked a fever, and her temperature remained elevated through her sixth day in the intensive care … 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 … First, both underdosing and overdosing are
associated with adverse clinical outcomes. … Venous thromboembolism is a condition commonly faced by both inpatient and outpatient clinicians.
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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
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 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/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - Innovator
Summary
Venous thromboembolism (VTE) is a serious but preventable medical condition … Implemented
2005
Problem Addressed
Deep vein thrombosis (DVT) is a medical condition … Defect-free care included receiving appropriate VTE prophylaxis care such as prescriptions and administration … https://www.hematology.org/education/clinicians/guidelines-and-quality-care/clinical-practice-guidelines … care and validity.
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - Positive answers to these survey items prompt further action or follow-up. … (should any modifications be made to the version tested in this innovation) and the implementation plan … or developer of the innovation. … Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes … Care (Psychiatry and Clinical Psychology)
Public Health
Diagnostic Errors
Provider-Patient