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psnet.ahrq.gov/issue/achieving-diagnostic-excellence-roadmaps-develop-and-use-patient-reported-measures-equity
November 02, 2022 - In this study, researchers used human-centered design principles , information from environmental scans
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psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
June 24, 2020 - The most frequent triggers included pressures from high census; environmental overload; chronic, unresolved
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psnet.ahrq.gov/issue/systematic-review-intraoperative-anesthesia-handoffs-and-handoff-tools
March 10, 2021 - April 7, 2021
Distraction in the operating room: a narrative review of environmental
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - A CT scan of the head
and cervical spine was obtained, which was normal. … This can be accomplished using an environmental checklist such as the one that has been used
in the … VHA since 2007.(13,14)
We have found that using a standard checklist for environmental rounds allows … Use a standard checklist to review the mental health unit for environmental hazards every 6 months. … Inpatient suicide on mental health units in Veterans Affairs
(VA) hospitals: avoiding environmental
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - also has recognized limitations, especially when the involved staff are both affected by
the same environmental
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psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - A CT scan showed no evidence of a new stroke. … therapeutic procedures,
https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
medication effects, and environmental … These protocols have historically focused on addressing environmental factors such as loud
noise, bright … hospitalized patients and is caused by underlying illness(es),
diagnostic and therapeutic procedures, and environmental
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psnet.ahrq.gov/web-mm/suicide-risk-hospital
November 01, 2011 - A CT scan of the head and cervical spine was obtained, which was normal. … This can be accomplished using an environmental checklist such as the one that has been used in the VHA … since 2007.( 13,14 ) We have found that using a standard checklist for environmental rounds allows … Use a standard checklist to review the mental health unit for environmental hazards every 6 months. … Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards
-
psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - practice also has recognized limitations, especially when the involved staff are both affected by the same environmental
-
psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital
pharmacy … may become inattentive to new stimuli (such as, in this case, failure of the medication barcode to scan … mortality rates.10 In this case, the ICU nurse may have been frustrated by the unexpected inability to scan … Within these 3 categories, a total of 31
probable causes have been identified,12 ranging from environmental
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for … may become inattentive to new stimuli (such as, in this case, failure of the medication barcode to scan … mortality rates. 10 In this case, the ICU nurse may have been frustrated by the unexpected inability to scan … Within these 3 categories, a total of 31 probable causes have been identified, 12 ranging from environmental
-
psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - A reader is used to scan the sponge onto the operative field
and then the sponge is rescanned when it … cavity/site procedures
• Personnel change
• High blood loss
Patient-specific factors
• High BMI
Environmental
-
psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - A CT scan showed no evidence of a new stroke. … causes, including underlying illness(es), diagnostic and therapeutic procedures, medication effects, and environmental … These protocols have historically focused on addressing environmental factors such as loud noise, bright … hospitalized patients and is caused by underlying illness(es), diagnostic and therapeutic procedures, and environmental
-
psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - An abdominal computed tomographic (CT) scan during the previous hospitalization had shown a metallic … In the present case, a CT scan was obtained at the time of the initial hospitalization, but the foreign … Listen to the Family
June 1, 2004
WebM&M Cases
Environmental
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - A reader is used to scan the sponge onto the operative field and then the sponge is rescanned when it … Personnel change • High blood loss Patient-specific factors • High BMI Environmental
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Psychiatric Emergency Services (PES)
• Medical record indicates multiple chronic diseases and recent CT
scan … and targets medical hospitals and
behavioral health organizations
4 Key Components (July 2019):
• Environmental … found to be
high risk for suicide include:
– Video observation
– 1:1 observation
– Minimization of environmental … patients
and provides useful information regarding a patient’s social resources,
coping skills, and environmental
-
psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Causes of wrong patient documentation are often multifactorial, including environmental (e.g. high
frequency
-
psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - not all, of patients’ determinants of health, from the health services themselves to the social and
environmental … comprehensiveness) and
providing whole-person care
Understanding how determinants of
health such as social and
environmental … Working with patients to help them
overcome barriers to equitable
care, such as access and social
and environmental … Environmental Scan of Primary Care-Based Efforts to Reduce
Readmissions.
-
psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Causes of wrong patient documentation are often multifactorial, including environmental (e.g. high frequency
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Environmental risk factors for delirium in hospitalized older people.
-
psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - indicated he had multiple chronic diseases and, of note, a suspicious lesion
(revealed by a recent CT scan … medical hospitals and behavioral health care organizations.3,4 Elements of these programs include
environmental … risk for suicide within the hospital include: video observation, 1:1 observation,
minimization of environmental … very useful information for a clinician regarding
a patient’s social resources, coping skills, and environmental