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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - looking at diagnostic errors across a
disease or clinical condition. … The specialty experts are clinicians (e.g., gynecologists) who have expertise
in the specific 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
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - hinder achievement of intended clinical outcomes. 1 The intervention was designed to identify potential … Getting Started with This Innovation
Determine the clinical conditions to focus on as part of the … Identify the commonly prescribed medications across the clinical conditions to incorporate into the automated … Develop criteria for identifying patients with a newly prescribed medication associated with one of the clinical … Office
Health Care Providers
Pharmacists
Health Care Executives and Administrators
Side Effects
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psnet.ahrq.gov/issue/healthcare-411-consumer-insider-medical-handoffs
October 18, 2006 - March 14, 2007
Health IT implementation stories: HANDS care plan tool seeks to improve … 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 … and Poor Communication at Discharge Leads to a PICC without a Plan. … July 8, 2020
Applying the Medications at Transitions and Clinical Handoffs Toolkit in
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psnet.ahrq.gov/issue/decade-patient-safety-2020-2030
December 21, 2005 - July 14, 2021
Global Patient Safety Action Plan 2021-2030: Towards Eliminating Avoidable … mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or … April 19, 2023
Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed). … adherence, and chronic condition control. … August 31, 2022
Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional
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psnet.ahrq.gov/issue/healthcare-411-provider-insider-medical-handoffs
October 18, 2006 - March 14, 2007
Health IT implementation stories: HANDS care plan tool seeks to improve … 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 … and Poor Communication at Discharge Leads to a PICC without a Plan. … July 8, 2020
Applying the Medications at Transitions and Clinical Handoffs Toolkit in
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - The following morning, his condition worsened and he had a respiratory arrest. … of other men in the clinic or of home physicians are not belittled by word or look. … One can imagine clinical situations in which the rationale for mandatory disclosure of another health … Respectful Management of Serious Clinical Adverse Events. … that a plan to prevent recurrences will be developed 7.
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - or delayed diagnosis of a non-COVID-19 condition because of the presumption that the patient has contracted … can better position their clinical teams for care for COVID-19 patients. … For example, artificial intelligence (AI) could be a beneficial tool to support clinical decision-making … are unable to move or turn when hemodynamically unstable and on a ventilator or extracorporeal life … Delay or avoidance of medical care because of COVID-19-related concerns--United States, June 2020.
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - or more specialized care for those disorders. … to push the check box in front of the providers and make it very hard to move to the next stage of clinical … How do you plan to prepare your service and hospitalists or other physicians for the implications of … patient safety revolution was to get patient safety on the radar screen and to have it be part of the clinical … To me the fundamental reason that care is not nearly as safe as it should be is that up until 7 or 8
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psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - In this commentary, we address these issues and provide potential solutions for clinical practice. … After the intrahospital transfer, the checklist may include reassessment of patient condition, a reminder … If the patient's condition requires it, the intrahospital transfer should be performed by qualified and … research has focused primarily on nurses and physicians, but failure to speak up is not limited to clinical … Clinical incidents that may or may not result in patient harm frequently occur during intrahospital transfer
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - In this world, physicians would know the
prevalence of each possible condition under consideration, … Premature closure: Once a plausible condition is identified, other possibilities are not fully
considered … Improving patient care. The cognitive psychology of missed diagnoses. … 94%.
10% or more of autopsies disclose important
discrepancies that would have changed the
clinical … care or prognosis.(1) Studies looking at
specific clinical conditions find an error rate of
approximately
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psnet.ahrq.gov/issue/examining-attitudes-hospital-pharmacists-reporting-medication-safety-incidents-using-theory
January 16, 2013 - Int J Qual Health Care . 2015; 27 (4) :297-304 . … February 23, 2018
Impact of a drug shortage on medication errors and clinical outcomes … in the pediatric intensive care unit. … September 23, 2015
Economic evaluation of the impact of medication errors reported by US clinical … Potentially inappropriate medications in a large cohort of patients in geriatric units: association with clinical
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - She was eventually successfully extubated and discharged home in good condition. … Recent European/American clinical practice guidelines have suggested that noninvasive ventilation be … Protocol directed weaning from mechanical ventilation: clinical outcome in patients randomized for a … Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. … Units
Health Care Providers
Critical Care
Pulmonology
Nonsurgical Procedural Complications
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - discharged to a skilled nursing facility (SNF) for physical therapy on low-molecular-weight heparin, with a plan … patient self-monitoring with point-of-care INR testing, increases the time in the therapeutic range … These systems are also likely to detect changes in the patient’s clinical condition or medication regimen … Treatment of warfarin-associated coagulopathy with oral vitamin K: a randomized clinical trial. … Health Care Providers
Non-Health Care Professionals
Medicine
View More
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psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change
November 16, 2022 - Missed diagnosis of a dangerous condition in utero, treatment errors , lack of response to concerns … January 13, 2021
Digital Clinical Safety Strategy
October 20, 2021 … January 9, 2024
Clinical Investigation Booking Systems Failures: Written Communications … July 22, 2020
Care Compare. … July 1, 2020
View More
See More About The Topic
Hospitals
Home Care
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psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordination-improve-health-system
November 29, 2009 - November 25, 2020
Meeting the Moment: Addressing Barriers and Facilitating Clinical Adoption … March 17, 2021
Implementing Optimal Team-Based Care to Reduce Clinician Burnout. … Interview
In Conversation With...Amy Helwig about Health Plan … July 10, 2024
Perspectives on Safety
Health Plan … July 31, 2013
Translating patient safety legislation into health care practice.
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psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
April 23, 2014 - April 23, 2014
Review into the Quality of Care and Treatment Provided by 14 Hospital … May 24, 2023
Digital Clinical Safety Strategy
October 20, 2021
Prep … July 23, 2023
Measuring team hierarchy during high-stakes clinical decision making: development … April 12, 2023
A high-reliability organization framework for health care: a multiyear … 2017
View More
See More About The Topic
Hospitals
Medicine
Nurse Care
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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/node/49624/psn-pdf
May 01, 2011 - The following
morning, his condition worsened and he had a respiratory arrest. … of other men in the clinic or
of home physicians are not belittled by word or look. … One can imagine clinical situations in which the rationale for mandatory disclosure of another health … Respectful Management of Serious Clinical Adverse
Events. … the patient what will be done differently to make recurrences less likely, or that a plan to prevent
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psnet.ahrq.gov/issue/impact-duty-hour-regulations-medical-students-education-views-key-clinical-faculty
May 20, 2019 - Study
Impact of duty hour regulations on medical students' education: views of key clinical … Impact of duty hour regulations on medical students' education: views of key clinical faculty. … Classification of health information technology safety events in a pediatric tertiary care … June 7, 2023
The quality of pharmacologic care for vulnerable older patients. … Resources
Association of residency work hour reform with long term quality and costs of care
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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.