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2821. Medication/Drug Errors | PSNet
      psnet.ahrq.gov/curated-library/medicationdrug-errors
      March 12, 2021 - Organizational Policy/Guidelines National Patient Safety Goals. … equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical … recommendations to improve medication safety for this vulnerable population, which includes integrating a clinical … Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following

2822. Two Wrongs Don't Make a Right (Kidney) | PSNet
      psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
      April 01, 2010 - Deficiencies in organizational planning, culture, and collaboration Lack of standardization of practice … guidelines Inadequate policies and noncompliance with those policies Lack of staff organization … The impact of computerized provider order entry on medication errors in a multispecialty group practice

2823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50696/psn-pdf
      November 27, 2019 - for respiratory compromise due to laryngeal edema and impingement of the airway.10 In this case, the clinical … setting is a reminder of the need for careful, frequent monitoring of all patients’ vital signs and clinical … Clinical decision support features in the EHR can also help to alert medical staff to high-risk patients … Practice guidelines for central venous access: a report by the American Society of Anesthesiologists … Clinical therapeutics. 1997 May 1;19(3):405-19. [go to PubMed] 6.

2824. In Conversation with…Pat Croskerry, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
      June 01, 2010 - Yet the uptake of clinical decision rules is abysmally low. … But at the end of the day, the clinical decision rule will outperform you, so why not use it? … (iv) ED systems for teamwork and handoffs as well as guidelines for procedures and checklists should … The effect of clinical experience on the error rate of emergency physicians. … Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41:110-120.

2825. If You Say So: Taking a Syringe at Face Value in the Operating Room | PSNet
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      January 01, 2015 - Advances include practice guidelines, newer and shorter acting medications, new equipment for airway … resident's willingness to raise and pursue safety concerns is affected by system, supervisor, trainee, and clinical … Audrey Lyndon, PhD, RN Professor and Assistant Dean for Clinical Research NYU Rory Meyers College of … Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical

2826. Watch the Warfarin! | PSNet
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      December 01, 2013 - machines that allow patients to check their own INR at home (as opposed to having to go to a lab or a clinical … communication between the inpatient and outpatient settings regarding changes in other medications, clinical … Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical … Practice Guidelines (8th Edition). … Meta-analysis: effect of patient self-testing and self-management of long-term anticoagulation on major clinical

2827. Operationalizing Patient Safety at Academic Medical Centers | PSNet
      psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
      August 01, 2010 - components of patient safety during a national consensus conference.( 6 ) In reviewing these educational guidelines … Chayan Chakraborti, MD Assistant Professor of Clinical Medicine Tulane University School of Medicine … Improving safety on the front lines: the role of clinical microsystems. … Assessing safety culture: guidelines and recommendations. Qual Saf Health Care. 2005;14:231-233. … Building a high reliability organization through a multi-method approach to monitoring the practice environment

2828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49606/psn-pdf
      August 01, 2010 - back and knee osteoarthritis, which severely limits physical activity and makes most forms of simple, clinical … There are existing practice guidelines that assist providers in managing perioperative glycemic control … be achieved with the operating room table in the reverse Trendelenburg position.(12) Therefore, our practice … anesthesia and surgical care provider will see more and more extremely obese patients in their daily practice … The morbidly obese patient presents a complex clinical https://psnet.ahrq.gov//#figure https://psnet.ahrq.gov

2829. Treatment Challenges After Discharge | PSNet
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      January 03, 2017 - Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. … Reducing office practice risks. Forum. 2000;20:1-21. [Available at]   13. … Communicating critical test results: safe practice recommendations. … January 3, 2017 ASHP guidelines on preventing medication errors with chemotherapy and … December 22, 2021 Implementation of the I-PASS handoff program in diverse clinical environments

2830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33756/psn-pdf
      October 01, 2013 - When we looked at patients grouped by clinical condition being assessed—such as PE or stroke—the doses … After we looked into it more closely, it turns out that there were very few guidelines about what doses … It turns out those doses have very little resemblance to the doses used in clinical practice. … It's hard to change practice without having the evidence basis for doing that. … But a private practice radiologist at the end—during a very exciting question and answer and comment

2831. Association of cataract surgical outcomes with late surgeon career stages: a population-based cohort study. | PSNet
      psnet.ahrq.gov/issue/association-cataract-surgical-outcomes-late-surgeon-career-stages-population-based-cohort
      September 23, 2020 - September 23, 2020 Effect of computerized provider order entry with clinical decision … February 14, 2024 Evidence-based guidelines for fatigue risk management in emergency

2832. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - Benchmarking (1) Critical Pathways (6) Patient Self-Management (2) Practice … Guidelines (30) Specialization of Care (15) Clinical Pharmacist Involvement … Technologic Approaches (55) Bar Coding and Radiofrequency ID Tagging (4) Clinical … The commentary provides an overview of the clinical manifestations of intraoperative durotomy, intra- … information and the importance of effective communication and active engagement among all clinical team

2833. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
      psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
      November 27, 2019 - This prevailing practice pattern placed the nurse at risk for medication errors associated with confirmation …  Education and training for physicians, nurses, and pharmacists must be provided prior to any major practice … However, cognitive biases associated with this practice can contribute to increased risk for error, especially … Retrieved April 16, 2021, from https://www.ashp.org/-/media/assets/pharmacy-practice/s4s/docs/s4s-iv-a … October 6, 2021 Patient safety in general practice during COVID-19: a descriptive analysis

2834. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
      psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
      April 09, 2014 - Appreciate that order sets may encourage a mechanistic focus that may prevent a deeper consideration of clinical … The combination of large volumes of information, inappropriate application of her usual practice (giving … If the usual practice for most patients is to "check all the boxes," then it is unlikely that we will … Published guidelines on the development of standard order sets should be followed. Anthony C. … Guidelines for standard order sets. P T. 2014;39:10-11,50.

2835. E-prescribing: E for error? | PSNet
      psnet.ahrq.gov/web-mm/e-prescribing-e-error
      February 03, 2021 - In addition, studies showed that clinical decision support systems change prescribing behavior and significantly … benefits of e-prescribing, including improved transmission and reduced medication errors, both physician practice … Document software design and workflow challenges to feedback to the vendor and provider practice for … Ashton, PharmD Health Sciences Assistant Clinical Professor Department of Clinical Pharmacy University … February 3, 2021 Surviving Sepsis Campaign: international guidelines for management of

2836. The Inside of a Time Out | PSNet
      psnet.ahrq.gov/web-mm/inside-time-out
      March 01, 2004 - the surgery or procedure regardless of where it is being performed.( 2 ) Despite the spirit of these guidelines … reason, New York State now requires that the time out take place immediately prior to the incision, a practice … behavior and apologized to the nurse, but was also told that the nursing staff would be establishing new guidelines … critical points prior to incision, such as just prior to placement of a spinal anesthetic, and this is a practice

2837. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
      psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
      September 01, 2012 - Unfortunately, this technique is still commonly performed in practice for multiple reasons, including … Medicine, Division of Cardiovascular Medicine UC Davis Health taipham@ucdavis.edu Surabhi Atreja, MD Clinical … October 11, 2023 The role of bias in clinical decision-making of people with serious … May 30, 2016 ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals

2838. What Do We Know About Emergency Department Safety? | PSNet
      psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
      June 01, 2010 - (iv) ED systems for teamwork and handoffs as well as guidelines for procedures and checklists should … The effect of clinical experience on the error rate of emergency physicians. … Yet the uptake of clinical decision rules is abysmally low. … July 12, 2017 Improving measurement in clinical handover. … A review of evidence, practice and consumer perspectives.

2839. Hidden Heparins: HIT Happens | PSNet
      psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
      March 27, 2024 - the median duration of HIT antibody positivity is 85 days.( 1 ) This observation has led to the usual practice … two clinical settings. … Heparin-induced thrombocytopenia and thrombosis: clinical and laboratory studies. … August 28, 2024 STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation … practice and the potential use of healthcare information technology to improve prescribing and patient

2840. In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
      May 14, 2020 - At GW, the Innovative Practice and Telehealth team is part of the largest multi-specialty group practice … Telehealth is often referred to or referenced as telemedicine (clinical services), but also includes … Guidelines Archive National Consortium of Telehealth Resource Centers COVID-19 Telehealth Resources … The protocols should align with existing clinical workflows and take into consideration the level of … All clinical staff within a given institution should be aware of these guidance documents and of when