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3281. Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach. | PSNet
      psnet.ahrq.gov/issue/operating-room-icu-patient-handovers-multidisciplinary-human-centered-design-approach
      June 27, 2012 - June 10, 2015 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022 Changes in medical errors after implementation of a handoff program. … FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in … November 16, 2022 Families as partners in hospital error and adverse event surveillance … : using a scoring tool to direct quality improvements in handover.

3282. Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? | PSNet
      psnet.ahrq.gov/issue/timely-follow-abnormal-diagnostic-imaging-test-results-outpatient-setting-are-electronic
      September 20, 2011 - Classic Timely follow-up of abnormal diagnostic imaging test results in … Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic … Inadequate follow-up of diagnostic testing is a known safety issue in both hospital and ambulatory … Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic … September 20, 2011 Identifying diagnostic errors in primary care using an electronic

3283. Understanding how the design and implementation of online consultations affect primary care quality: systematic review of evidence with recommendations for designers, providers, and researchers. | PSNet
      psnet.ahrq.gov/issue/understanding-how-design-and-implementation-online-consultations-affect-primary-care-quality
      October 05, 2022 - This systematic review examined the types of online consultation available to patients in primary care … January 12, 2022 Impact of remote consultations on antibiotic prescribing in primary … multidisciplinary medication review on the safety and medication cost of the elderly people living in … February 12, 2020 Habit and automaticity in medical alert override: cohort study. … February 10, 2021 View More Related Resources Patient safety in

3284. Procedure Complications – Who is Responsible for Follow up? | PSNet
      psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
      July 31, 2023 - ), and a 35% decrease in mean length of hospital stay (13 versus 20 days). 5 These data underscore … March 27, 2019 Hospital characteristics associated with penalties in the Centers for … Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program. … six Belgian hospitals. … April 1, 2003 View More See More About The Topic Hospitals Operating

3285. Medical Devices in the "Wild" | PSNet
      psnet.ahrq.gov/web-mm/medical-devices-wild
      March 27, 2024 - coronary artery disease, diabetes, chronic pain, arthritis, and hyperlipidemia was admitted to the hospital … After a short period of treatment, his swelling improved and he was able to ambulate on the hospital … This reactive change may be limited to just one hospital and likely did not result in more systemic changes … Doyle, PhD Human Factors Engineer Johns Hopkins Hospital Clinical Engineering Department … February 1, 2003 View More See More About The Topic Hospitals

3286. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49839/psn-pdf
      August 01, 2018 - psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital … He had been seen at another hospital 2 weeks earlier for a similar episode, with a glucose level of … discharge, the patient experienced another severe hypoglycemic episode and was admitted to a different hospital … falls and even deaths in elderly patients.(9) Medication review may help prevent these types of events … drug use in elderly patients.

3287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61078/psn-pdf
      October 28, 2020 - Based on the experiences of these authors, it typically falls on the patient/family and consulting diabetes … Hospitals do not typically stock pump or CGM supplies11, and thus the patient should be responsible … Hospital. … Diabetes Care in the Hospital: Standards of Medical Care in Diabetes- 2020. … Management of Type 1 Diabetes in the Hospital Setting. Curr Diab Rep 2017;17:98.  22.

3288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866622/psn-pdf
      August 28, 2024 - Sarah Mossburg: When operationalizing Safety-II, were you using these tools in one hospital, one unit … or huddle with direct frontline team members regarding a specific safety concern, such as patient falls … We noticed that with hospital-acquired infection, it took some time for us to get to the point where … problematic or high- risk processes, like our response to work, workforce safety events, our inter-hospital … A hospital in New York presented the concept of performing a success cause analysis after care is provided

3289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49779/psn-pdf
      January 01, 2017 - web-mm/empty-bag The Case A 90-year-old woman with end-stage dementia was admitted to an acute care hospital … colleagues suggest that by involving various stakeholders and considering a range of frontline needs, hospitals … There is a lack of coordination between pump requirements and hospital capabilities. … Injuries are caused by a lack of differentiation between the use of infusion devices in hospitals and … Products designed for the hospital environment are being used in home environments (and vice versa).

3290. In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring | PSNet
      psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
      March 15, 2023 - patients, which could reduce the risk of heart attack and stroke that may lead to potential disability and falls … augment that with telehealth where you get a view into someone's home and see if there are tripping or falling … setting. 6 , 7 These programs were aimed at reducing the burden on hospitals at times of increased … hospital utilization and detecting any change in status of patients. … See More About The Topic Researchers General Public Emergency Departments Specialty Hospitals

3291. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73200/psn-pdf
      April 28, 2021 - to the hospital,?the patient? … Failure to consult or communicate with subspecialty providers early in the hospital course for glycemic … Hospitals should also employ dedicated multidisciplinary teams for inpatient diabetes care, to guide … Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019.  … care units: impact on 30-day readmission rate and hospital cost.

3292. Remote Patient Monitoring | PSNet
      psnet.ahrq.gov/perspective/remote-patient-monitoring
      March 15, 2023 - setting. 6 , 7 These programs were aimed at reducing the burden on hospitals at times of increased … hospital utilization and detecting any change in status of patients. … patients, which could reduce the risk of heart attack and stroke that may lead to potential disability and falls … augment that with telehealth where you get a view into someone's home and see if there are tripping or falling … More See More About The Topic General Public Emergency Departments Specialty Hospitals

3293. Failed Interpretation of Screening Tool: Delayed Treatment | PSNet
      psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
      August 20, 2018 - infection can initially present with nonspecific symptoms including fatigue, generalized weakness, falls … a poor positive predictive value (approximately 40%) and may not improve in-hospital survival.( 8 ) … When screening infected patients outside the ICU, qSOFA has slightly better predictive value for in-hospital … US hospitals using clinical vs claims data, 2009--2014. … a multistate hospital network--13 academic medical centers, April-June 2020.

3294. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
      September 24, 2024 - I think it's good for CMS to try to hold hospitals accountable for some of these things. … A better structural measure could direct hospitals to set a goal for year-over-year improvement in the … Sarah Mossburg:  You’ve talked about the importance of incremental goals that hospitals have the means … reporting, and decreases in preventable harm: 39% decrease in injuries with falls, 37% fewer pressure … Indeed, the amount of effort expended in the resource scarce environment of hospital administration suggests

3295. A framework for assessing reasoning about controversial end-of-life clinical decisions. | PSNet
      psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
      November 30, 2023 - Later in the hospital course, he required abscess drainage by an interventional radiologist. … a multistate hospital network--13 academic medical centers, April-June 2020. … September 23, 2020 A national profile of patient safety in U.S. hospitals. … safety score for US hospitals. … May 31, 2023 Patient Safety Innovations Preventing Falls

3296. Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care | PSNet
      psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
      July 23, 2024 - Michael’s Hospital; Toronto General Hospital; University of Pittsburgh Medical Center Health Plan; Indiana … Center; Geisinger Health System; Penn Medicine; Duke University Health System; New York City Health & Hospitals … ; Yale New Haven Health; Dartmouth-Hitchcock; Brigham and Women’s Hospital. … Getting Started with This Innovation Get the health system or hospital leadership’s support. … May 31, 2023 Patient Safety Innovations Preventing Falls

3297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33824/psn-pdf
      January 01, 2016 - the idea of pain as a "fifth vital sign," and the inclusion of pain-related questions on the HCAHPS [Hospital … Consumer Assessment of Healthcare Providers and Systems] survey, whose results can affect hospital … In this sense, the opioid epidemic is iatrogenic, and thus falls within the scope of patient safety. … and colleagues reported that Medicare beneficiaries (age 65 and older) are often discharged from the hospital … The Agency for Healthcare Research and Quality has several efforts https://psnet.ahrq.gov/issue/hospital-prescribing-opioids-medicare-beneficiaries

3298. Cultural Competence and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
      December 27, 2019 - to a lack of timely language assistance include performing an x-ray on the wrong part of the body, falls … Language proficiency and adverse events in US hospitals: a pilot study. … A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. … https://www.ahrq.gov/health-literacy/systems/hospital/lepguide/index.html . … If you’re looking at rates of infection in a hospital over a period of time, moving the needle on those

3299. In Conversation With… Gregg S. Meyer, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
      June 01, 2016 - When I first came back to the provider organization side as a medical director in a large hospital, about … Together we look at communication, processes, data, and outcomes in hospital operations. … When a patient falls victim to a medication error, the employees may experience heightened emotions and … With limited resources and personnel in most hospitals, the poster session equips attendees with essential … Heparin overdose in three infants revisits hospital error issues. MedPage Today.

3300. Volume Too Low: In and Out | PSNet
      psnet.ahrq.gov/web-mm/volume-too-low-and-out
      July 01, 2017 - In sharp contrast, in the average children's hospital, the range of patients' body weight can vary from … The deterioration of children in ward areas in a specialist children's hospital. … hospital. … Related Resources Patient Safety Innovations Preventing Falls … Mishap September 1, 2003 View More See More About The Topic Hospitals