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psnet.ahrq.gov/issue/structured-approach-ehr-surveillance-diagnostic-error-acute-care-exploratory-analysis-two
October 16, 2024 - Study
A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
Citation Text:
Malik MA, Motta-Calderon D, Piniella N, et al. A structured approach to EHR surveillance of diagnostic error in acute car…
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psnet.ahrq.gov/issue/electronic-triggers-identify-delays-follow-mammography-harnessing-power-big-data-health-care
September 28, 2016 - Study
Electronic triggers to identify delays in follow-up of mammography: harnessing the power of big data in health care.
Citation Text:
Murphy DR, Meyer AND, Vaghani V, et al. Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health…
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psnet.ahrq.gov/issue/effect-patient-and-family-centered-i-pass-adverse-event-rates-hospitalized-children-complex
November 16, 2022 - Study
Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions.
Citation Text:
Kuzma N, Khan A, Rickey L, et al. Effect of Patient and Family Centered I‐PASS on adverse event rates in hospitalized children with complex c…
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psnet.ahrq.gov/node/34737/psn-pdf
November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems
Failure. … https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
This video, produced … https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure … The patient had two apparent indications for an ACE inhibitor: type 2 diabetes and congestive
heart failure … predispose to hyperkalemia—diabetes because of
hyporeninemic hypoaldosteronism and congestive heart failure … In the Randomized
Aldactone Evaluation Study (RALES), only 1.7% of heart failure patients treated with … The effect of spironolactone on morbidity and mortality in patients
with severe heart failure.
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hcup-us.ahrq.gov/reports/factsandfigures/2008/pdfs/section4.pdf
January 01, 2008 - Between 1997 and 2008, costs for acute renal failure, septicemia, and respiratory failure grew at … implant or graft 5.7 8.4 11.5 2.5 2.8 3.1 6.5
Congestive heart failure … other back problems 3.6 6.2 9.5 1.6 2.0 2.6 9.4
Respiratory failure … , septicemia, and respiratory failure grew at two to
three times the rate of total hospital costs. … , mood disorders, and acute renal failure
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hcup-us.ahrq.gov/reports/factsandfigures/2008/figures/2008_4_1b.jsp
January 01, 2008 - AGGREGATE COSTS IN BILLIONS
MEAN COST
Mood disorders
824
$4.2
$5,100
Acute renal failure … 798
$7.4
$9,300
Acute cerebrovascular disease
565
$7.6
$13,400
Respiratory failure … back problems
663
$9.5
$14,400
Pneumonia
1,156
$10.5
$9,000
Congestive heart failure
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psnet.ahrq.gov/node/46773/psn-pdf
January 24, 2018 - /issue/patient-safety-complementary-medicine-through-application-clinical-risk-
management-public
Failure … This study describes the application of failure mode and effect analysis to better understand the
patient … patient-safety-complementary-medicine-through-application-clinical-risk-management-public
https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
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psnet.ahrq.gov/node/33653/psn-pdf
June 01, 2007 - In response to "Failure to Report" (March 2007)
June 1, 2007
Paparella S, Vaida AJ, Spath P. … In response to "Failure to Report" (March 2007). PSNet [internet]. 2007. … https://psnet.ahrq.gov/perspective/response-failure-report-march-2007
In response to "Failure to Report … the vials that accompanied the commentary, we felt that
https://psnet.ahrq.gov/perspective/response-failure-report-march … -2007
https://psnet.ahrq.gov/web-mm/failure-report
the manufacturers had done a fairly good job of
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure … The patient had two apparent indications for an ACE inhibitor: type 2 diabetes and congestive heart failure … predispose to hyperkalemia—diabetes because of hyporeninemic hypoaldosteronism and congestive heart failure … In the Randomized Aldactone Evaluation Study (RALES), only 1.7% of heart failure patients treated with … The effect of spironolactone on morbidity and mortality in patients with severe heart failure.
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hcup-us.ahrq.gov/reports/statbriefs/sb194-Inpatient-Mortality-High-Volume-Conditions.jsp
July 01, 2015 - decreasing for high-volume conditions, such as acute myocardial infarction (AMI), congestive heart failure … 41 percent decrease for acute myocardial infarction (AMI), 29 percent decrease for congestive heart failure … the number of deaths per 1,000 hospital admissions for acute myocardial infarction, congestive heart failure … Deaths per 1,000 hospital admissions for congestive heart failure were 44.4 in 2002, 42.5 in 2003, 41.3 … primary payer, 2002-2012
Abbreviations: AMI, acute myocardial infarction; CHF, congestive heart failure
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hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/section5_9.pdf
January 01, 2007 - 100.0% 100.0% 27%
Non-specific chest pain 48 91 13.4 20.3 91
Congestive heart failure … Appendicitis 27 46 8.8 11.1 68
Respiratory 527 537‡ 100.0 100.0 2
Respiratory failure … disorders) 147 193 31.0 36.3 32
Genitourinary 152 195 100.0 100.0 28
Acute renal failure … Medicaid hospital stays for some conditions more than doubled from 1997 to 2007:
Acute renal failure … Respiratory failure (up 125 percent).
Anemia (up 118 percent).
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psnet.ahrq.gov/node/45599/psn-pdf
July 02, 2017 - combined the narratives of various critical care nurses into four representative
scenarios demonstrating failure … environments can miss an
important event because of competing attentional tasks, as a key factor in these failure-to-rescue … invisible-gorilla-and-other-ways-our-intuitions-deceive-us
https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study
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psnet.ahrq.gov/node/47756/psn-pdf
February 06, 2019 - psnet.ahrq.gov/issue/meltdown-why-our-systems-fail-and-what-we-can-do-about-it
Complex systems are prone to failure … This book provides a multi-industry discussion of factors that
contribute to failure. … highlight how complexity can exacerbate problems, small glitches can
manifest themselves in large-scale failure
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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - resulting in transfer
to an acute-care hospital and contributing to death
• Pneumonia and respiratory failure … treated with ineffective medication for
several days, leading to increased bruising, respiratory failure … Cascade with septic shock related to urinary catheter with delayed recognition leading to
respiratory failure … contributing to death
• Fungal central line-associated bloodstream infection leading to acute renal failure … , requiring acute-care hospital care, and ultimately death
• Altered mental status and respiratory failure
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psnet.ahrq.gov/node/45393/psn-pdf
November 16, 2016 - for Healthcare Research and Quality (AHRQ)
Patient Safety Indicator for Postoperative Respiratory
Failure … for Healthcare Research and Quality (AHRQ)
Patient Safety Indicator for Postoperative Respiratory Failure … independent physician chart review to assess the reliability of PSI 11
(postoperative respiratory failure
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hcup-us.ahrq.gov/reports/infographics/HCUP-hospital-readmission-infographic-final.pdf
July 15, 2014 - ,
infection, or burn
patients with these common
diagnoses was readmitted:
25% Congestive heart failure … 22% Schizophrenia
22% Acute and unspecified
renal failure
patients with these less frequent … readmissions than other payers
Procedure: Amputation of lower extremity Diagnosis: Congestive heart failure
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hcup-us.ahrq.gov/reports/factsandfigures/2008/figures/2008_4_2.jsp
January 01, 2008 - ANNUAL GROWTH IN DISCHARGES PER POPULATION
AVERAGE ANNUAL GROWTH IN POPULATION
Acute renal failure … care, fitting of prostheses, and adjustment of devices
2.2%
1.7%
-0.6%
1.0%
Respiratory failure … 3.5%
-1.8%
1.0%
Cardiac dysrhythmias
6.6%
3.5%
2.0%
1.1%
Congestive heart failure
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This … Case: Failure to Report
Several hours later, when removing another vial of ceftriaxone from the automated … of safe guards
RN failure to confirm med identity prior to administration
An environment predisposed … Case: Failure to Report (cont.) … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10720336
Failure to Acknowledge Errors
Even when
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digital.ahrq.gov/sites/default/files/docs/resource/James_Fricton_IQHIT_Q1_HP_Recommendations_for_Preventing_Complications_for_Chronic_Illnesses.pdf
January 01, 2005 - Renal failure
f. Thyrotoxicosis
g. Chronic obstructive lung disease
3. … Asymptomatic heart failure, previous MI, LV dysfunction, valvular heart disease III. … Renal failure
f. Thyrotoxicosis
g. Chronic obstructive lung disease
3. … Asymptomatic heart failure, previous MI, LV dysfunction, valvular heart disease III. … The incidence and prevalence of
congestive heart failure in Rochester, Minnesota.