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psnet.ahrq.gov/node/73412/psn-pdf
August 01, 2022 - substance use during pregnancy.1
IPV is poorly addressed in most healthcare settings,1 and missed or … morbidity or mortality.2 As such,
this innovation sought to explore how teaching healthcare teams to … 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 … For more information or questions, please email
psnetsupport@ahrq.hhs.gov.
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psnet.ahrq.gov/node/844553/psn-pdf
February 15, 2023 - mental-health-conditions-leading-cause-pregnancy-related-deaths
Maternal safety is compromised by a range of social, cognitive, and clinical … It recommends screening, a care safety
plan, and the warm handoff as strategies to improve safety.
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - 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/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - This relationship can enhance communication, manage clinical information, facilitate transitions in care … Inadequate communication, poorly coordinated transitions between care settings, lack of current clinical … We had community health workers work with medical providers to come up with a care plan that they went … Once the individual is linked to primary care, the in-clinic staff can further implement the care plan … , while the community health workers can support adherence to the care plan in the community setting.
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psnet.ahrq.gov/issue/review-bringing-patient-safety-forefront-through-structured-computerisation-during-clinical
January 13, 2021 - Review: bringing patient safety to the forefront through structured computerisation during clinical … This review explores handoff methods in the clinical setting, discusses risks for adverse events in … July 23, 2014
Bedside handover: quality improvement strategy to "transform care at the … April 21, 2010
Health IT implementation stories: HANDS care plan tool seeks to improve … The Topic
Hospitals
Nurses
Nurse Managers
Quality and Safety Professionals
Nurse Care
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was … 11)
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 … reduce anesthesia time or turnover time.
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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/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/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - looking at diagnostic errors across a disease or clinical condition. … After most studies, current clinical and operational teams are assigned responsibility (or new teams … patients with a certain condition or event. … Electronic clinical surveillance to improve outpatient care: diverse applications within an integrated … or developer of the innovation.
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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Eligible patients include those who require hospitalization for a condition such as community-acquired … Nurses use illness-specific, hospital-at-home care maps and clinical outcome evaluations to determine … When patients refused to be admitted, the physicians found themselves patching together a care plan that … organizations, integrated delivery systems like the VA, and systems that have a health plan and providers … Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical
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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/issue/health-plan-members-views-about-disclosure-medical-errors
November 15, 2011 - Health plan members' views about disclosure of medical errors. … Health plan members' views about disclosure of medical errors. … support on adverse drug events in the long-term care setting. … July 20, 2011
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … June 5, 2013
Error or "act of God"?
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - , or in the intermediate care setting, versus the general care setting. … So, if you use the condition-specific monitoring approach in the general care setting where the prevalence … Our research shows if you set up alerts at traditional ICU levels, or even a more condition-specific … We always find things we didn’t expect—you can’t plan it all. … Providers
Clinical Technologists
Health Care Executives and Administrators
View More
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psnet.ahrq.gov/web-mm/confusion-acetaminophen
December 01, 2009 - 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 recommend … Heubi, MD Professor of Pediatrics Assistant Dean for Clinical Research University of Cincinnati College … of Medicine Program Director, General Clinical Research Center Cincinnati Children's Hospital Medical … A practitioner-based randomized clinical trial. JAMA. 1995;273:929-933. [ go to PubMed ] 2.
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - His
complex health condition was known to his wife, and given the very complex nature of the surgery … However, the surgeon identified an error in the team’s intraoperative care that may
or may not have … Unfortunately, in this case, there was
no plan or commitment made to the widow to follow up with her … The patient’s clinical care should be explained and questions about it answered as extensively as possible … After the clinical care and recommended improvements are explained, the clinicians involved should
excuse
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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/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/web-mm/too-many-cooks-kitchen
March 07, 2018 - distributing health care goods or services consumed by, or used on patients” and relevant financial … aortic stenosis is a known risk for anesthesia, 5 and the high relative mortality conferred by this condition … Optimal care of frail patients hinges on a plan with the least possible perioperative stress, both surgical … No simple fix for fixation errors: cognitive processes and their clinical applications. … Design of a Novel Multifunction Decision Support Display for Anesthesia Care: AlertWatch® OR.
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - plan in the context of that environment.2
Building on prior studies, a team at the Cleveland Clinic … home care. … AHRQ had no role in the study design or reporting. … Overview of Clinical Conditions with Frequent and
Costly Hospital Readmissions by Payer, 2018. … For more information or questions, please email
psnetsupport@ahrq.hhs.gov.
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psnet.ahrq.gov/issue/patient-misidentification-oncology-care
March 22, 2006 - Commentary
Patient misidentification in oncology care. … Citation Text:
Patient misidentification in oncology care. Schulmeister L. … Cite
Citation
Citation Text:
Patient misidentification in oncology care … November 10, 2021
Nursing bedside clinical handover—an integrated review of issues and … June 14, 2019
Medication double-checking procedures in clinical practice: a cross-sectional