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psnet.ahrq.gov/periodic-issue/periodic-issue-289
April 28, 2021 - Hearing impairment can lead to misunderstanding of a patient’s health condition, treatment, or follow … In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for … handoffs in their clinical education or on-the-job training. … unsafe, missed, or delayed care. … The patient was discharged in stable clinical condition but was advised to quarantine for 14 days.
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - The mother was taken to the recovery room in stable condition. … unit in critical condition. … routine and concealed obstetric hemorrhage as well as those obscured by confounding diagnoses and provide clinical … Maternity Care. … ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October
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psnet.ahrq.gov/periodic-issue/periodic-issue-280
February 10, 2021 - Study
Measurement matters: changing penalty calculations under the hospital acquired condition … Since 2014, Medicare’s Hospital-Acquired Condition Reduction Program (HACRP) reduces payments to hospitals … family understood the medication plan or could identify symptoms of side effects. … (R21/R33 - Clinical Trial Optional). … clinical decision making.
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - Edwin Boudreaux : I am a clinical psychologist by training. … Instead, they get care there, or they get connected to other care, and they can be diverted from the … Often, when we make a discharge plan with a patient in the facility, they are not in a good condition … health condition. … It is a stigmatized condition, and people often feel rejected.
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - The mother was taken to the recovery room in stable condition. … unit in critical condition. … and
concealed obstetric hemorrhage as well as those obscured by confounding diagnoses and provide clinical … Maternity Care. … ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76,
October
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psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
March 25, 2025 - Edwin Boudreaux : I am a clinical psychologist by training. … Instead, they get care there, or they get connected to other care, and they can be diverted from the … Often, when we make a discharge plan with a patient in the facility, they are not in a good condition … health condition. … It is a stigmatized condition, and people often feel rejected.
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - “Thus, clinicians facing patients at risk of [acute compartment syndrome] must choose a treatment plan … Educate the patient and family in plain language about the patient’s condition, the discharge process … Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s … care to the patient and family and use teach back. … In a study of 30,727 members of a
commercial health plan, patients discharged after hospitalization
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - This objective is achieved by formulating a
management plan that takes into consideration severity of … The required clinical and laboratory evaluations were not performed despite the fact that the
nurse … in management of her condition, such as a high-risk specialist. … dysfunction as well; in
these patients, it may be difficult to distinguish a worsening underlying medical condition … All facilities providing care for obstetric or postpartum patients should also develop mechanisms that
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - condition (i.e., type 1 diabetes) is crucial. … be able to diagnose diabetic ketoacidosis (DKA) early, as it is a life-
threatening yet preventable condition … for
diabetes due to lack of access to care or the high costs of insulin in the United States. 2 … management of their sick
days, how to trouble-shoot pump malfunction, and how to develop a backup plan … Do professional interpreters improve clinical care for
patients with limited English proficiency?
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - 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. … May 25, 2011
A reduction in cardiac arrests and duration of clinical instability after
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - Face-to-face meeting with PCP to gain plan approval: Once the care plan is developed, the
support team … her home to
review the care plan and patient goals. … condition(s) recognized or diagnosed, receive a specialty consultation, and be provided with
appropriate … a health plan affiliated with either or both of these programs). … opportunity for a health
plan or health care system to realize cost savings through the implementation
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - physician assistant), nurse, care manager, or social worker), quality improvement (QI) facilitator, … errors; prescription-related issues; and follow-up plan and access issues. … discharge process, but the time will be well spent, as it will enhance patients' understanding of their condition … Available at: https://www.hospitalmedicine.org/clinical-topics/care-transitions/
SHM Project Boost … Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
December 01, 2011 - On hospital day two, the team discussed the plan for ongoing anticoagulation. … teams through use of video, pictures, text messaging, or email
See Notes for references … to clinical information if a patient’s clinical condition changes rapidly
Enhance communication among … transmit harmful bacteria
Electromagnetic radiation emitted could potentially disrupt hospital equipment or … orders have not been completed
*
*
Solutions to Reduce Risks
Institutions may implement rules or
-
psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - with an increasing oxygen requirement,
ultimately requiring intubation and transfer to the intensive care … As a result of multiple communication failures, necessary care
was delayed, and the patient rapidly … management issues, confirmation of a treatment plan, risk
assessment and reassurance, or documentation … she is serving with regard to the patient's care. … have responded in a timely fashion (4)
and would have realized the emergent nature of the patient's condition
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - This objective is achieved by formulating a management plan that takes into consideration severity of … in management of her condition, such as a high-risk specialist. … dysfunction as well; in these patients, it may be difficult to distinguish a worsening underlying medical condition … All facilities providing care for obstetric or postpartum patients should also develop mechanisms that … Providers
Risk Managers
Obstetrics
Clinical Misdiagnosis
View More
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - evaluation , requires physicians to ask what gaps might exist in their understanding of the patient's condition … she has the knowledge and skill to care for a condition outside his or her primary scope of practice … health plan. … care
October 2, 2019
Blink or think: can further reflection improve initial diagnostic … November 28, 2012
How teams work—or don’t—in primary care: a field study on internal
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psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
June 14, 2017 - Med Care. 2016;54(12):1105-1111. … Establishing hospital quality or payment based on unvalidated metrics has consequences for patient safety … June 14, 2017
Potential harms resulting from patient–clinician real-time clinical encounters … March 12, 2025
Clinical communities at Johns Hopkins Medicine: an emerging approach to … 7, 2020
Changes in hospital safety following penalties in the US Hospital Acquired Condition
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psnet.ahrq.gov/node/49585/psn-pdf
May 01, 2009 - Despite the patient's deteriorating clinical
condition, the patient's worsening level of consciousness … Her condition did not significantly
improve, and she eventually died 2 weeks later. … Incorporating their contribution into the plan of care is strongly recommended.
James L. … Delirium in the intensive care unit:
occurrence and clinical course in older patients. … hospital care.
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - Encounter and claims data indicate if a health plan member is seen in a clinic, a hospital, or even if … 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. … , we often think of strategies that can be implemented at the health care organization or health care
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - managing the patient was uncertain as to whether
the psychosis was due to a “primary” psychiatric condition … (e.g.,
schizophreniform disorder, schizophrenia) or a systemic medical condition,
so two consultations … • This patient could have had a favorable result with this management plan, but we
will never know … predominant
presentation of psychosis reduced the likelihood of the patient seeking primary
medical care … • In this context, the lack of a primary care physician to coordinate post-discharge
care may have