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3501. Hidden Mystery | PSNet
      psnet.ahrq.gov/web-mm/hidden-mystery
      December 01, 2011 - She died of multiorgan failure after a complex several-month hospital course. … a panel of hospitals. … hospital practice: factors associated with turnover, outcomes, and patient safety. … August 20, 2018 Families as partners in hospital error and adverse event surveillance … Appendicitis June 1, 2003 View More See More About The Topic Hospitals

3502. Double Dosing, by the Rules | PSNet
      psnet.ahrq.gov/web-mm/double-dosing-rules
      February 03, 2010 - The medications were administered by the night-shift nurse when they arrived on the unit at 6:00 AM, in … For example, in this case, both the night and day nurses followed the 5 Rights when they administered … care, and changes in level of care. … Technology Responses to COVID-19 July 21, 2020 Financial incentives to reduce hospital-acquired … December 9, 2020 Safety enhancements every hospital must consider in wake of another

3503. The University of Texas System Clinical Safety and Effectiveness Course | PSNet
      psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
      February 01, 2011 - At UT Southwestern, the program is given in collaboration with Parkland Health and Hospital System and … A hospital-randomized controlled trial of an educational quality improvement intervention in rural and … small community hospitals in Texas following implementation of information technology. … A hospital-randomized controlled trial of a formal quality improvement educational program in rural and … QI and cost Implemented ABC program in 16 Texas rural hospitals and 2 Pennsylvania rural hospitals

3504. But See the Patient First | PSNet
      psnet.ahrq.gov/web-mm/see-patient-first
      September 27, 2023 - Overnight on hospital day 2, the patient’s temperature was 38.7°C on a routine vital sign check, with … Both sets of blood cultures remained negative and the patient was discharged on hospital day five with … Hopefully, the results of this study will be useful to hospital systems trying to gain perspective on … Tight Control May 1, 2004 View More See More About The Topic Hospitals … Quality and Safety Professionals Hospital Medicine Medical Complications Latent Errors

3505. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet
      psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
      March 01, 2015 - hospitals with elevated HSMRs, no differences were seen compared to hospitals with lower HSMRs in adherence … over time within individual hospitals, thus circumventing much of the confounding inherent in between-hospital … Identifying variations in quality of care in Queensland hospitals. Med J Aust. 2007;187:571-575. … all the hospitals—in the newspaper. … In his report he said that all 14 hospitals had problems.

3506. In Conversation With... José A, Morfín, MD, FASN | PSNet
      psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
      April 28, 2021 - In Conversation With... … I am also the medical director at two of the programs, one in Sacramento and one in Folsom. … KH : It sounds like, between in-home and in-facility dialysis, the concerns are similar. … include infections, hypotension, electrolyte disturbances, blood loss, adverse drug effects, and patient falls … Home Care Nephrology Side Effects/Adverse Drug Reactions Nosocomial Infections Patient Falls

3507. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33822/psn-pdf
      January 01, 2017 - we had similar circumstances in plants in Russia, China, Hungary, or any place in the world, as long … hospitals with a central line had a central line infection, and that was considered normal and inevitable … Rick Shannon, who was then at the Allegheny General Hospital in charge of three intensive care units … The University of Pittsburgh Medical Center has about 22 hospitals. … Children's Hospital.

3508. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet
      psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
      November 25, 2020 - Three days later, the patient was admitted to a second hospital with perforated bowel and sepsis. … Among 167 and 205 patients who presented to two community hospitals with normal total leukocyte counts … bands; adjusted OR, 6.2, 95% CI, 3.2-11.8 for high bands), including gram-negative bacteremia, and in-hospital … investigation in this setting. … September 29, 2021 WebM&M Cases EMS Perils from Hospital

3509. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Part of this commentary is based on my experience as a physician in Vietnam in the 1960s and 34 years … In a systematic review of 7000 refugees, PTSD was found in 9% and major depression in 5%, with considerable … comorbidity.(4) In a study in Australia, long-term Vietnamese refugees had a prevalence rate of PTSD … There are several important changes clinics and hospitals can make to address the needs of refugee patients … In: Okparu SO, ed. Clinical Methods in Transcultural Psychiatry.

3510. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60268/psn-pdf
      April 29, 2020 - Almost a decade ago, Arkansas Children's Hospital reported seven adverse events in 57 transfers (12.3% … emergencies Intra-hospital/in-hospital ECMO transport team Critical ECMO transport team members would … programs, that professional may not always be available in-hospital or, as in the current case, may … Check that device supply/supplies are connected to the most secure source/s, i.e. in hospital plugs for … In-Hospital Neurologic Complications in Adult Patients Undergoing Venoarterial Extracorporeal Membrane

3511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850361/psn-pdf
      June 14, 2023 - After the patient was readmitted with endocarditis, he had a complicated hospital course resulting in … in this case involved the transition from hospital to skilled nursing facility. … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … The incidence and nature of in-hospital adverse events: a systematic review. … Adverse Events in Hospitals: Case Study of Incidence Among Medicare Beneficiaries in Two Selected Counties

3512. Late Anemia Following Rh Disease in a Newborn | PSNet
      psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
      June 17, 2010 - clinicians now recognized that the infant had active Rh hemolytic disease, and he was admitted to the hospital … , which causes benign, mild jaundice in adults and can contribute to elevated bilirubin levels in newborns … In addition, although it is common in patient safety discussions to focus on errors of omission ( 9 ) … a community hospital network. … Pregnancy June 1, 2010 Finding blunders in thyroid testing: experience in

3513. Add-on Case and the Missing Checklist | PSNet
      psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
      September 01, 2012 - In 2009, an estimated 6.9 million esophagogastroduodenoscopy (EGD) procedures were performed in the United … Burden of gastrointestinal disease in the United States: 2012 update. … Implementation of safety checklists in surgery: a realist synthesis of evidence. … of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals … in England: lessons from the "Surgical Checklist Implementation Project."

3514. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33726/psn-pdf
      March 01, 2012 - In Conversation With… Richard C. Boothman, JD March 1, 2012 In Conversation With… Richard C. … In the early days of my career, you didn't see very many catastrophic verdicts in medical malpractice … RW: Was your theory in moving in this direction that not only was this the right thing to do but there … How does the brand new risk manager at a 150-bed community hospital in Ypsilanti get this work done? … It can be reproduced in a private setting in all sorts of ways.

3515. In Conversation With... James Augustine, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-james-augustine-md
      July 28, 2021 - You are there to interact with the hospitals in the area, particularly during emergency events, to make … your community and with your hospitals. … issue shortly after it occurred, or when something is falling out of their usual case management. … In some cities with hospitals that have developed that level of sophistication, they now put CT scans … to the right hospital.

3516. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49516/psn-pdf
      August 01, 2006 - In this regard, physicians in the United States differ from our colleagues in Canada and England, who … training might compound the risk of patients like this falling through the cracks. … Bias creeps in. … One of us (G.R.T.) has seen a patient with spinal cord injury who was transferred from an outside hospital … clinics in Africa or India.

3517. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49591/psn-pdf
      October 01, 2009 - As with most training hospitals, residents are not credentialed by the medical center and their behavior … each of the hospitals in which they rotate. … I would also expect them to warn him that insulting behavior toward nurses or any other hospital staff … from hospital to hospital or state to state, in my experience, the overall flavor is similar. … Safety and quality innovations that were incorporated into our daily hospital operations (eg, rapid

3518. Too Many Cooks in the Kitchen | PSNet
      psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
      March 07, 2018 - While being assisted to a standing position on hospital day 13, the patient’s left leg buckled and he … , venous thromboembolism and  hospital acquired-infection . 8  Pneumonia leading to sepsis and organ … Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam Dressings.  … Pneumonia in hospitalized elderly hip fracture patients: the effects on length of hospital-stay, in-hospital … Comparison of Early Warning Scoring Systems for Hospitalized Patients With and Without Infection at Risk for In-Hospital

3519. Hiding in Plain Sight | PSNet
      psnet.ahrq.gov/web-mm/hiding-plain-sight
      April 24, 2019 - Hiding in Plain Sight Citation Text: Weinberg JM. Hiding in Plain Sight. … Hiding in Plain Sight. PSNet [internet]. … Background Herpes zoster (or shingles) occurs in approximately 1 million people annually in the United … Hiding in Plain Sight. PSNet [internet]. … April 24, 2019 An inpatient fall prevention initiative in a tertiary care hospital.

3520. Video to Improve Patient Safety: Clinical and Educational Uses | PSNet
      psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
      March 01, 2004 - surgery ( 1 ) may mark a new frontier in the use of video in medicine. … Notification that video surveillance occurs in patient care areas is usually included in hospital admission … In one case conference in which video vignettes of trauma patient resuscitation were shown, a senior … in a Level 1 trauma center. … with MRSA April 1, 2008 View More See More About The Topic Hospitals