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2781. Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial. | PSNet
      psnet.ahrq.gov/issue/patient-readmissions-emergency-visits-and-adverse-events-after-software-assisted-discharge
      November 16, 2022 - Resources From the Same Author(s) Implementation of the I-PASS handoff program in diverse clinical … July 29, 2020 Surviving Sepsis Campaign: international guidelines for management of sepsis

2782. How can patient-held lists of medication enhance patient safety? A mixed-methods study with a focus on user experience. | PSNet
      psnet.ahrq.gov/issue/how-can-patient-held-lists-medication-enhance-patient-safety-mixed-methods-study-focus-user
      February 16, 2022 - February 16, 2022 User-testing guidelines to improve the safety of intravenous medicines

2783. Milliliters vs. Milligrams | PSNet
      psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
      September 01, 2004 - Consequently, additional safeguards, such as computerized prescriber order entry (CPOE) with real-time clinical … Finally, clearly defined standards of practice in medication dispensing procedures should be in place … Poole, PharmD Director of Pharmacy, Lucile Packard Children's Hospital at Stanford Clinical Professor … Medication error prevention by clinical pharmacists in two children's hospitals. … Guidelines for preventing medication errors in pediatrics.

2784. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet
      psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
      October 02, 2013 - errors), and lack of consensus about correct diagnostic process (compared with violations of therapeutic guidelines … Typical estimates place the overall diagnostic error rate in clinical practice in the range of 10%–15% … Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384. … Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41:110-120. … practice.

2785. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences | PSNet
      psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
      December 18, 2019 - Physician understanding and application of surrogate decision-making laws in clinical practice. … The U-ARE Protocol: A Pragmatic Approach to Decisional Capacity Assessment for Clinical Research. … August 13, 2014 Using a claims data-based sentinel system to improve compliance with clinical … guidelines: results of a randomized prospective study. … More See More About The Topic Hospitals Hospital Medicine Palliative Care Clinical

2786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73642/psn-pdf
      August 25, 2021 - bleeding, bowel perforation, infection, and reactions to administered medications.2,3 The Pediatric Clinical … Adult guidelines recommend monitoring blood pressure, oxygenation, and heart rate along with clinical … In children, guidelines and several studies recommend performing upper endoscopy under general anesthesia … Pediatric Endoscopy and High-risk Patients: A Clinical Report From the NASPGHAN Endoscopy Committee. … Guidelines for sedation and anesthesia in GI endoscopy.

2787. Urine a Tough Position | PSNet
      psnet.ahrq.gov/web-mm/urine-tough-position
      January 01, 2009 - One could imagine this error remaining undiscovered until the patient presented months later with clinical … Often, patients deliver throat swabs, lab requisitions, x-rays, and other clinical items to various sites … Therefore, verification of patient identification and proper labeling of specimens, requisitions, and clinical … Then, clinical staff can collaborate to design fail-safe mechanisms for ensuring proper specimen identification … Clear guidelines for this specimen process should be created and processes audited to ensure compliance

2788. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet
      psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
      January 29, 2021 - recognized early, providers can initiate early life-saving treatments and management. 12 According to guidelines … increases by 8% and mortality increases by 4-9%. 12,13 In addition to antibiotic therapy, the sepsis guidelines … Diagnostic errors and the bedside clinical examination. … Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines … Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021.

2789. Autopsy Revelation | PSNet
      psnet.ahrq.gov/web-mm/autopsy-revelation
      December 01, 2007 - postgraduate educational criteria (except in pathology), the dropping of minimum autopsy rates from regulatory guidelines … Clinical correlation is advised." … Autopsy consent practice at US teaching hospitals: results of a national survey. … Analysis of inaccuracies in clinical diagnoses and their significance. … Autopsy diagnoses of malignant neoplasms: how often are clinical diagnoses incorrect?

2790. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49440/psn-pdf
      March 01, 2004 - educational criteria (except in pathology), the dropping of minimum autopsy rates from regulatory guidelines … Clinical correlation is advised." … Autopsy consent practice at US teaching hospitals: results of a national survey. … Analysis of inaccuracies in clinical diagnoses and their significance. … Autopsy diagnoses of malignant neoplasms: how often are clinical diagnoses incorrect?

2791. In Conversation With... David Gruen, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-david-gruen-md
      January 31, 2020 - David Gruen: I have worked in a varied assortment of healthcare environments, from private practice … to hospital-based practice, and the one common denominator has been that radiologists can’t keep up. … with the literature on the latest advances and guidelines. … KH: Where are we with radiologists using AI in their practice? … Artificial intelligence, bias and clinical safety.

2792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49670/psn-pdf
      November 01, 2012 - CAP), resulting in significant morbidity, mortality, and a total cost of more than $10 billion.(1) Guidelines … A thorough history and physical exam must be combined with sound clinical judgment to differentiate … For example, several well-validated clinical prediction rules have been combined with measurement of … This particular patient's Wells clinical prediction tool for PE results in a score of 1.5 (points are … Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management

2793. Equity in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/equity-patient-safety
      September 24, 2024 - One such strategy is discussed in the context of clinical medical education : an unconscious bias could … Technology and Equity Tools such as algorithms or pulse oximeters may inadvertently influence clinical … less trustworthy to clinicians than older clinical decision support tools based on expert knowledge … and guidelines. … Among the early outcomes from this project is greater partnership in scholarship and clinical training

2794. In Conversation with...Sir Liam Donaldson, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
      May 01, 2007 - Most doctors, at least in my country, are not assessed once they've gone into autonomous practice—for … We have produced guidelines on reporting systems so that people didn't make the mistakes of some of the … Mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice … This organization inspects hospitals against risk management standards and optimal clinical practice, … Results from the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376.

2795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865658/psn-pdf
      April 24, 2024 - States have varying staffing requirements and guidelines. … It would have been a best practice if the administrator had notified the nurse on call or the resident … Ron Ordona, DNP, FNP-BC, GS-C, WCC Health Sciences Assistant Clinical Professor Betty Irene Moore School … Bakerjian, PhD, APRN, FAANP, FGSA, FAAN Co-Editor-in-Chief, AHRQ’s Patient Safety Network (PSNet) Clinical … On-Call Geriatric Psychiatry: Handbook of Principles and Practice. Springer; 2016.

2796. Point-of-care Mixup: 1 Shot Turns Into 3 | PSNet
      psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
      February 14, 2024 - the immunization process.( 5 ) Doubt and suspicion often color, and even disrupt, evidence-supported practice … case, the nurse's error owed, at least in part, to a systemic problem of vaccine management within the practice … Where there is uncertainty, advice line services can improve the accuracy and quality of immunization practice … Reducing pain during vaccine injections: clinical practice guideline. CMAJ. 2015;187:975-982. … Reducing immunization discomfort in 4- to 6- year old children: a randomized clinical trial.

2797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853902/psn-pdf
      September 27, 2023 - recognized early, providers can initiate early life-saving treatments and management.12 According to guidelines … increases by 8% and mortality increases by 4-9%.12,13 In addition to antibiotic therapy, the sepsis guidelines … Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines … Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. … Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021.

2798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33665/psn-pdf
      March 01, 2008 - inpatient medical procedures; (ii) better determine when a trainee is competent by assessing both clinical … Direct faculty supervision helps offset the costs of the program, as attendings now generate clinical … intensive learning experience provides the resident multiple, condensed opportunities for deliberate practice … The assessment of clinical skills/competence/performance. Acad Med. 1990;65(suppl 9):S63-S67. … (3)   Table 2: Beth Israel Deaconess Internal Medicine Residency 2007–2008 Procedural Competency Guidelines

2799. In Conversation With… Linda Aiken, PhD, RN | PSNet
      psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
      March 01, 2018 - why safety interventions that have been shown to work under controlled circumstances don't work in practice … We also saw huge variation in nurses' ratings of their practice environment, with around 40% of all nurses … show a similar finding for patient experience.( 7 ) The findings have implications for policy and practice … to deliver complete care, but also to policymakers and leaders who fail to translate research into practice … Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice

2800. Missed Nursing Care: A Key Measure for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
      March 01, 2018 - show a similar finding for patient experience.( 7 ) The findings have implications for policy and practice … to deliver complete care, but also to policymakers and leaders who fail to translate research into practice … Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice … why safety interventions that have been shown to work under controlled circumstances don't work in practice … We also saw huge variation in nurses' ratings of their practice environment, with around 40% of all nurses