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3441. Mother's Milk, but Whose Mother? | PSNet
      psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
      November 15, 2023 - In light of the difficulties associated with regular breastfeeding in the hospital, the mother stored … her pumped breast milk in the refrigerator on the infant's ward in the hospital. … the event that a donor mother refuses testing.( 8,14 ) Preventing Breast-Milk Errors in a Hospital … Had bar coding been available in this hospital, unique identifiers for this infant would have been scanned … May 11, 2005 View More See More About The Topic General Hospitals Nurses

3442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865884/psn-pdf
      May 29, 2024 - unsteady gait, suggesting pelvic muscle weakness and requiring use of a “tether” to keep her from falling … On hospital day 12, the patient was discharged with diagnoses of “intractable nausea and vomiting,” … one; the endoscopy with dilation did not improve the patient’s symptoms and she was admitted to the hospital … Upon readmission to the hospital, with the patient even more severely ill, the problem representation … Olson, MD, FACP, FAAP Associate Professor of Medicine and Pediatrics Director, Division of Hospital

3443. In Conversation with...Patrick Tighe about Artificial Intelligence | PSNet
      psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
      March 27, 2024 - In terms of improving access to care, hospitals are bursting at the seams across the United States right … Perhaps this isn’t terribly dissimilar from hospital pharmacies. … There are pharmacy and therapeutics committees at hospitals continually looking at this information, … in the healthcare setting and can alert staff when a patient falls or a critical checklist step is skipped … Acute Hospital Care Units April 26, 2023 Perspectives on Safety

3444. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49708/psn-pdf
      May 01, 2014 - In a consensus statement issued by the Society of Hospital Medicine, an integrated and easily transferable … Deficits in communication and information transfer between hospital-based and primary care physicians … Medication reconciliation in the hospital: what, why, where, when, who and how? … Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems … Effect of medication reconciliation on medication costs after hospital discharge in relation to hospital

3445. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865429/psn-pdf
      April 24, 2024 - in every hospital that has a cardiac catheterization laboratory; transfer to a regional center is often … who present to rural or safety net hospitals with limited capabilities. … the cardioversion shock must be synchronized with the ECG to prevent the shock from inadvertently falling … to hospitals with and without revascularization services. … Audit of defibrillators at an urban public sector hospital. Heart Asia. 2018;10(2):e011065.

3446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49732/psn-pdf
      May 01, 2015 - obstructive pulmonary disease (COPD) on home oxygen, and coronary artery disease presented to the hospital … She died on hospital day 4 with her family at her bedside. … Hospital data can be collected and analyzed and feedback on performance should be provided to individuals … Doing so could have dramatically altered her hospital course; whereby she might not have deteriorated … To be successful, it must have a multidisciplinary approach involving nurses, providers, and hospital

3447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33652/psn-pdf
      June 01, 2007 - invites hospitals to participate in expert subcommittees with local health department staff to review … a hospital alert. … Hospitals were expected to develop and implement procedures based on the report. … relation to length of stay and total charges; compare indicator trends for a hospital with hospitals … in its peer group, a hospital corporate system, and aggregate state data; and stratify results by sociodemographic

3448. Retained Surgical Items: Definition and Epidemiology. | PSNet
      psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
      September 15, 2024 - These items are NOT “foreign” bodies or objects; they are supplies or devices that the hospital or facility … All RSI cases are usually required to be reported to internal hospital risk management and patient safety … Most states that require mandatory event reporting, the American Hospital Association Coding Clinic, … Monitoring and reporting hospital-acquired conditions: a federalist approach. … Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Patient falls

3449. The Safety of Medical Devices | PSNet
      psnet.ahrq.gov/perspective/safety-medical-devices
      June 01, 2011 - Warranty and USFDA approval concerns precluded the hospital from modifying the equipment. … The hospital developed a report of the event for the manufacturer. … Letters: How to reduce tube mix-ups in hospitals. New York Times. August 25, 2010:A26. 7. … This is true in government, and it would be true in industry, and I suspect it would also be true in … Hospital managers have to be especially aware of the risks of hierarchic organizations.

3450. Failure to Rescue the Mother | PSNet
      psnet.ahrq.gov/web-mm/failure-rescue-mother
      September 23, 2020 - The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for … Gregory, MD, MPH The United States spends more than any other country on hospital-based maternity care … Standardized ratios vary (6:4:1 vs 4:4:1), but should be consistent throughout the hospital.( 4 ) In … a multistate hospital network--13 academic medical centers, April-June 2020. … hospital practice: factors associated with turnover, outcomes, and patient safety.

3451. Check Twice, Transport Once | PSNet
      psnet.ahrq.gov/web-mm/check-twice-transport-once
      March 15, 2023 - Throughout the hospital, there can be variability in how patients are transported, which is often dictated … Incidence of patient safety events and process-related human failures during intra-hospital transportation … Incidence of adverse events associated with the in-hospital transport of critically ill patients. … Ticket to ride: reducing handoff risk during hospital patient transport.  … , 2003 View More See More About The Topic Patient Transport Hospitals

3452. The Unhappy Patient Leaves Against Medical Advice. | PSNet
      psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
      January 31, 2024 - During the night shift, the hospital unit was short-staffed, and her external catheter system fell off … In the US, each year, 1-2% of all hospital discharges (involving approximately 500,000 patients) are … Had this process happened in the current case, the patient may have considered staying in the hospital … in Beirut, Lebanon. … Another Fall April 1, 2003 View More See More About The Topic Hospitals

3453. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
      January 01, 2024 - this case, combined operations cannot be performed in every hospital that has a cardiac catheterization … patients who present to rural or safety net hospitals with limited capabilities. – Delays in such transfers … the cardioversion shock must be synchronized with the ECG to prevent the shock from inadvertently falling … to hospitals with and without revascularization services. … Audit of defibrillators at an urban public sector hospital. Heart Asia. 2018;10(2):e011065.

3454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33771/psn-pdf
      August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014. … in disability or death.(4) In a study of 400 patients discharged from a tertiary academic hospital, … On the other hand, hospitals with advanced decision support systems were able to detect or prevent 70% … we have learned from the hospital, some advances in ambulatory patient safety will come from our growing … help inform future improvement efforts in the hospital.

3455. Production Pressures | PSNet
      psnet.ahrq.gov/web-mm/production-pressures
      November 16, 2022 - A second anesthesiologist in the group spends the day in the operating room (OR) supervising three nurse … Very often, changes in workload occur in health care in an unpredictable manner. … such days—for example, could an anesthesiologist be pulled from a critical care unit or an affiliated hospital … January 20, 2021 Information flow during pediatric trauma care transitions: things falling … Fumbled Handoff March 1, 2004 View More See More About The Topic Hospitals

3456. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - "( 1,2 ) Nevertheless, this error continues to occur in numerous hospitals annually with a relatively … constant event rate of 0.04 to 0.08 reported events per 1000 staffed hospital beds.( 3 ) In order to … in any procedure. … Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. … a multistate hospital network--13 academic medical centers, April-June 2020.

3457. Elopement | PSNet
      psnet.ahrq.gov/web-mm/elopement
      July 14, 2010 - In the course of his ED visit, no one questioned the presence of a hospital ID bracelet and hospital … Pleading and practice forms, hospitals. In: American Jurisprudence. 2nd ed. … Hospitals and asylums. In: American Jurisprudence. Vol 40A. 2nd ed. … July 14, 2010 A strategic approach for managing conflict in hospitals: responding to … December 21, 2014 Clinical deterioration and hospital‐acquired complications in adult

3458. In Conversation with…William B. Weeks, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
      May 01, 2009 - were complications at the hospital, the profit margin for the hospital was reduced but not eliminated … WW : That will provide a nice incentive for hospitals to address the issue. … So think of yourself managing a hospital, and people from Dartmouth come in and say, "You need to reduce … Where do you see the translation falling short? … Hospital Transport?)

3459. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
      July 01, 2005 - Impatient Inpatient Dosing An elderly man with a diagnosis of acute deep venous thrombosis (DVT) during hospital … warfarin If albumin less than 1.8, patient will be sensitive to warfarin As patients recover out of the hospital … In a Hurry? … A randomized, controlled trial in a teaching hospital. … Pharmacist-provided anticoagulation management in United States hospitals: death rates, length of stay

3460. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49823/psn-pdf
      March 01, 2018 - The patient was admitted to the hospital and given broad-spectrum antibiotics and a diagnosis of "influenza … Bacak, DO, MPH Maternal–Fetal Medicine Specialist Akron Children's Hospital Assistant Professor of Ob … Ob/Gyn Division of Maternal–Fetal Medicine University of Rochester Medical Center/Strong Memorial Hospital … Poisoning in pregnancy. In: Foley MR Jr, Strong TH, Garite TJ, eds. … in rats in vivo.