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psnet.ahrq.gov/node/49539/psn-pdf
June 01, 2007 - https://psnet.ahrq.gov/web-mm/informed-or-misled
The Case
A 50-year-old man arrived at the hospital … The patient reportedly signed an anesthesia
permit required by this hospital that stated that any change … Documentation merely acts as evidence that a discussion
took place; it does not absolve the clinician or the hospital … This is particularly relevant if hospital
policy requires that consent be obtained in advance of the … White, FRCA, BSc, MA Consultant Anaesthetist, Brighton and Sussex University Hospitals NHS
Trust, UK
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - for more than 500,000 hospital admissions and 10,000 inpatient deaths annually. … In-hospital deaths were rare, occurring in only 0.3% of admissions.( 1 ) However, brisk gastrointestinal … A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper … patient safety improvement project on hospital-wide adverse event outcomes and patient safety culture … Antibiotic Use
June 1, 2003
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Hospitals
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - , or even adaptations in existing hospitals. … In the traditional design of a hospital, you set
it up in a hierarchy of space from sterile to non-sterile … In China, they put in place what they call a fever hospital, and it
serves as a triage center. … the
future in hospitals in terms of tracking patient conditions. … How do we make their careers in the hospital more sustainable?
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psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - In a couple of intensive care units in a single hospital, it is pretty difficult to measure a difference … In our study it didn't cost anything more, because at Brigham & Women's Hospital, the internal medicine … CL: I think that the hospital has been rather bold in stepping up and saying that this is something … In the next few months, you'll see other interviews and essays covering topics such as how hospitals … research on preventing falls in nursing homes, or a physician interested in strategies to prevent wrong-site
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - As members of the Patient Safety Movement Foundation, we were the first hospital in the world to commit … In the early 2000’s, I was at another hospital in another state and I was the VP of Nursing. … EL : It is, we do a lot of tactical processes similar to a lot of other hospitals. … Case studies highlighting successful implementation of the concepts of SAB in a variety of hospitals … Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
December 18,
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - been widely used.5 Recently, the Centers
for Medicare & Medicaid Services (CMS) started requiring hospitals … to use the SAFER guides as part of the
FY 2022 Hospital Inpatient Prospective Payment Systems (IPPS … psnet.ahrq.gov/issue/medication-safety-emergency-department-study-serious-medication-errors-reported-101-hospitals … Guidelines for US hospitals and clinicians on assessment of
electronic health record safety using SAFER … Trends in US hospital electronic health record vendor market
concentration, 2012–2021.
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - not been widely used.5 Recently, the Centers for Medicare & Medicaid Services (CMS) started requiring hospitals … Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER … Trends in US hospital electronic health record vendor market concentration, 2012–2021. … Epilogue
April 1, 2009
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Hospitals … General Hospitals
Emergency Departments
Health Care Providers
Clinical Technologists
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - Management of hypertension in the setting of acute ischemic stroke. … with intravenous rtPA
Strategies that can compress treatment time for eligible patients include:
Pre-hospital … diverse locations in the hospital
Immediate neurologic evaluation may be limited
Nursing and other staff … : retrospective analysis of hospital quality assurance data with comparison with results from randomised … improving stroke-related outcomes and identifies hospitals that adhere to current evidence-based practices
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - "( 2 ) Of all medication-related hospital admissions in the United States, up to 69% may be due to poor … community hospital, given his bouncing back and forth between them. … One can imagine a rosier future, in which integrated information systems (hospital-clinic-lab-pharmacy-patient … OR Leads to Anticoagulation Mishap
December 1, 2017
Predictors of in-hospital … 31, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - Geriatric Patients
Older adults are at risk for adverse events from medications, including delirium and falls … Adverse drug events in elderly patients receiving home health services following hospital discharge. … The rate and nature of medication errors among elderly upon admission to hospital after implementation … STAAR: improving the reliability of care coordination and reducing hospital readmissions in an academic … the hospital
Performed predischarge bedside counseling
Contacted patient 48 hours after discharge
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - to a worsening wound from an amputation of the first metatarsal of right great toe at a different
hospital … Upon hospital admission, she was stabilized medically and sent to surgery for a trans-metatarsal foot … the perioperative setting to aid in pain and sedation efforts. … While this
topic falls outside of the scope of this commentary, it remains critical to treat the whole … In: Bradley WG, Daroff RB, Fenichel G, Jankovic J (eds).
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - Appreciate some of the steps hospitals take to prevent identification errors. … Hospitals are deploying computerized tools to cope with this landscape. … This policy was actually in effect in the author's own hospital, he writes, "and now I understand for … When physicians treat members of their own families: practices in a community hospital. … March 1, 2023
Information flow during pediatric trauma care transitions: things falling
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - The nurse's failure to confirm the medication's identity prior to administration falls into the category … A study of hospital nursing units found that higher reporting rates were correlated with unit members … In: Spath PL. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. … Checking for biases in incident reporting. In: Phimister JR, Bier VM, Kunreuther HC. … Week Itch
April 1, 2003
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Hospitals
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - Case studies highlighting successful implementation of the concepts of SAB in a variety of hospitals … As members of the Patient Safety Movement Foundation, we were the first hospital in the world to commit … In the early 2000’s, I was at another hospital in another state and I was the VP of Nursing. … EL : It is, we do a lot of tactical processes similar to a lot of other hospitals. … Perspective
The Ongoing Journey to Prevent Patient Falls
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - preventable”
One of eight conditions given this designation
Based on this, CMS stopped reimbursing
hospitals … for these complications when they
occur in the hospital
Organizations publish pressure ulcer rates … Medicare’s decision to withhold payment for hospital errors: the devil is in the details. … stay
CMS denial of reimbursement for pressure ulcers that develop in hospital is based on physician … Pressure ulcers may already be evolving on hospital admission in patients admitted with hip fracture.
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - In the previous 365 days, she had spent 199 days hospitalized (54% of the year) at one hospital. … patient between settings, services, practitioners or levels of care. 7 Settings of care may include hospitals … The data in PDMPs are state-specific and various settings/organizations in addition to hospitals, such … Society of Hospital Medicine. … patient safety and reducing medical errors in hospital settings: a narrative review.
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - In preparation for an upcoming JCAHO inspection, the small community hospital (which had suffered from … a monitoring
device, we should have an alarm (19) for automatically indicating when that parameter falls … inconvenience the patient's family and represent a potential
revenue loss for the surgeon and the hospital … In: Veatch R, ed. Medical ethics. … In: Bogner MS, ed. Human error in medicine.
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - focused on transitions necessitated by transfer to a different setting of care
(e.g., discharge from the hospital … "falling through the cracks" compared with other types of transfers. … in the ambulatory setting. … Handoffs in which the patient resides in the clinical setting (e.g., nursing homes,
acute hospital) … In addition, the verbal sign-out should
occur in a quiet setting with the written sign-out in hand and
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - in one patient, such as the patient in this case. … Courts will usually respect a medical decision if a rationale that falls within a reasonable range of … 2023
Information handoff and outcomes of critically ill patients transferred between hospitals … to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital … Related Resources
WebM&M Cases
Walking Out of a Hospital
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psnet.ahrq.gov/node/49661/psn-pdf
August 01, 2012 - the hospital setting have shifted to freestanding surgical centers and
offices.(1) The key factors … However, the risks
associated with general anesthesia are similar to those in the hospital setting. … In recent years, regional anesthesia use has grown in ambulatory surgery, a key contributing factor to … Traditionally, the
consent process for hospital-based interventions focuses on discussion of potential … strength and educate patients about the need for certain precautions to prevent
unintentional injury or falls