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3521. Delayed Diagnosis of Kidney Transplant Complications | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
      January 29, 2020 - Slow graft function alone, as in the patient in this case, has not traditionally been a factor that prompts … In this case, the patient’s slow graft function in the immediate post-transplant period did not necessitate … Approach to Improving Safety Safety in management of kidney transplant patients in the early post-transplant … Kidney ultrasound is useful tool in posttransplant follow-up. … Castration January 1, 2004 View More See More About The Topic Hospitals

3522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73229/psn-pdf
      May 26, 2021 - procedure, the patient experienced bradycardia and cardiac arrest within 9 hours of admission to the hospital … soft tissue necrosis), cardiac dysrhythmia, extravasation, acute kidney injury, increased duration of hospital … In this case, norepinephrine was used to achieve higher mean arterial pressure (MAP) goals in an attempt … In patients experiencing shock, weight is an insignificant factor in dosing norepinephrine, as catecholamine … is a critical factor as in pediatrics.8  The disadvantage of non-weight-based dosing in this population

3523. A Potent Medication Administered in a Not So Viable Route | PSNet
      psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
      July 20, 2016 - Complications were seldom seen in peripheral infusions given for short durations in proximal areas such … In a single-center observational study done in Long Island, 734 patients received vasopressor medications … the study hospital. … A complete ban on the use of peripheral vasopressor infusion, as was done by the hospital in response … In summary, when faced with a patient in shock refractory to adequate fluid resuscitation, the administration

3524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49690/psn-pdf
      September 01, 2013 - Commentary—Part 1 A 42-year-old man with a history of asthma and chronic lower back pain was admitted to the hospital … On admission to the hospital, he was treated with nebulizers, antibiotics, and prednisone. … of morphine equivalents in the United States in 1997 to 710 mg in 2010—enough to supply every adult … after discharge, the patient was found unconscious at a subway station and pronounced dead at a local hospital … Radiology Director of Endovascular Neurosurgery and Neuroendovascular Program, Massachusetts General Hospital

3525. Complications of ECMO During Transport | PSNet
      psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
      January 27, 2021 - 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 … programs, that professional may not always be available in-hospital or, as in the current case, may … In-Hospital Neurologic Complications in Adult Patients Undergoing Venoarterial Extracorporeal Membrane … Acute Hospital Care Units April 26, 2023 Medical crisis checklists in the

3526. The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department | PSNet
      psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
      October 30, 2024 - its 1,000-bed adult hospital. … Begin to get buy-in from all levels of staff and promote the issues addressed by the innovation as hospital-level … National Hospital Ambulatory Medical Care Survey: 2015 emergency department summary tables. … National Hospital Ambulatory Medical Care Survey: 2015 emergency department summary tables. … History March 21, 2009 View More See More About The Topic Hospitals

3527. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
      psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
      November 27, 2019 - procedure, the patient experienced bradycardia and cardiac arrest within 9 hours of admission to the hospital … soft tissue necrosis), cardiac dysrhythmia, extravasation, acute kidney injury, increased duration of hospital … In this case, norepinephrine was used to achieve higher mean arterial pressure (MAP) goals in an attempt … complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital … in 38 countries (PRICOV-19).

3528. Hold the tPA | PSNet
      psnet.ahrq.gov/web-mm/hold-tpa
      July 29, 2020 - In order to expedite treatment (crucial because research finds benefit for thrombolysis in acute stroke … However, in the rush to administer the tPA in the 3-hour time window, she was given the tPA before her … the community—in more than 50% of patients treated in some early series.( 2,5,6 ) When examined in a … associated with increased in-hospital mortality.( 2 ) The most common protocol deviations were treatment … Thrombolysis for acute stroke in routine clinical practice.

3529. Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates | PSNet
      psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
      October 30, 2024 - The all-cause mortality rate among individuals in the program is 81% lower than in individuals with untreated … Decrease in quantity of controlled substances . … and implement an innovation in behavioral health.   … NEJM Catalyst Innovations in Care Delivery. … Patient Safety Innovations Enhancing Support for Patients’ Social Needs to Reduce Hospital

3530. The Pains of Chronic Opioid Usage | PSNet
      psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
      April 04, 2018 - On admission to the hospital, he was treated with nebulizers, antibiotics, and prednisone. … after discharge, the patient was found unconscious at a subway station and pronounced dead at a local hospital … Radiology Director of Endovascular Neurosurgery and Neuroendovascular Program, Massachusetts General Hospital … the hospital setting: a qualitative study. … Man With Gun May 1, 2003 View More See More About The Topic Hospitals

3531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853081/psn-pdf
      August 30, 2023 - a second unit in another hospital. … hospital settings. … We’re going to scale VIC across 142 hospitals in the next five years. … Sarah Mossburg: You mentioned that you’re scaling VIC up to 142 hospitals in the next five years. … Imagine if, ten years later, the nurse who’s taking care of you in the hospital is actually the same

3532. Difficult Encounters: A CMO and CNO Respond | PSNet
      psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
      March 01, 2018 - 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. … the hospital setting: a qualitative study.

3533. Weighing In on Surgical Safety | PSNet
      psnet.ahrq.gov/web-mm/weighing-surgical-safety
      August 04, 2021 - in functional capacity. … Richard's Hospital Chichester, UK   Faculty Disclosure: Dr. Brodsky and Dr. … a children's hospital. … multistate hospital network--13 academic medical centers, April-June 2020. … Hygiene Compliance May 1, 2014 A case for safety leadership team training of hospital

3534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836794/psn-pdf
      March 31, 2022 - A study in King’s College Hospital found 31% of patients were determined to lack mental capacity, and … similar studies in general hospitals have found 9-52% of patients lacked mental capacity.1 Thus, it … There is a major gap in access to palliative care outside the hospital, and it is not uncommon for these … of Neurology UC Davis Health kapasao@ucdavis.edu Pouria Kashkouli, M.D., FACP Clinical Professor Hospital … & Palliative Medicine Department of Internal Medicine, Division of Hospital Medicine UC Davis Health

3535. EMS Patient Safety in the Field | PSNet
      psnet.ahrq.gov/perspective/ems-patient-safety-field
      July 28, 2021 - to the right hospital. … 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

3536. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - Around 10 days after hospital discharge, the patient was seen by the neurosurgeon, who now recommended … Most hospitals utilize some form of peer review to identify care process and system solutions that can … An online survey of 339 institutions including 61 teaching hospitals confirmed that most facilities have … Falling through the cracks: information breakdowns in critical care handoff communication. … Opportunities to improve clinical summaries for patients at hospital discharge.

3537. Can Research Help Us Improve the Medical Liability System? | PSNet
      psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
      March 01, 2012 - The error is intercepted by the hospital pharmacist before the medication is scheduled to be administered … Allen Kachalia, MD, JD Associate Chief Quality OfficerBrigham & Women's Hospital References   … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … How does the brand new risk manager at a 150-bed community hospital in Ypsilanti get this work done? … July 8, 2020 Inpatient Notes: mistakes in the hospital—communicating, apologizing, and

3538. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - How does the brand new risk manager at a 150-bed community hospital in Ypsilanti get this work done? … The error is intercepted by the hospital pharmacist before the medication is scheduled to be administered … Allen Kachalia, MD, JD Associate Chief Quality OfficerBrigham & Women's Hospital References   … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … September 21, 2005 View More See More About The Topic Hospitals Health

3539. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - • A few hours later, the clinic surgeon further reviewed the prior hospital record and noted the … are under-read because the primary inquiry was satisfied. 25 PEG Tube Complications (4) • Most hospitals … to enhance radiologists’ performance. – An online survey of 339 institutions including 61 teaching hospitals … Falling through the cracks: information breakdowns in critical care handoff communication. … Opportunities to improve clinical summaries for patients at hospital discharge.

3540. The Deadly Duo | PSNet
      psnet.ahrq.gov/web-mm/deadly-duo
      April 28, 2021 - May 5, 2014 The effects of hospital-physician financial integration on adverse incident … the Children's Hospitals' Solutions for Patient Safety Collaborative. … March 20, 2019 Resource-based view on safety culture's influence on hospital performance … : a study of U.S. hospitals. … October 27, 2021 Speaking up about patient safety in psychiatric hospitals - a cross-sectional