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3561. In Conversation With… Robert M. Wachter, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
      August 01, 2015 - If a second report was released next week, where do you see health IT falling in the pecking order relative … Personally, I would not see a doctor or go to a hospital that did not have an electronic health record … There were so many challenges for doctors in their offices and for hospitals to go through the turmoil … Or patients who went to UCSF did better than patients who went to another hospital. … , MPH September 1, 2007 View More See More About The Topic Hospitals

3562. In Conversation with...Dean Schillinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
      March 01, 2009 - Robert Wachter, Editor, AHRQ WebM&M: You work in a county hospital with underserved populations, which … at public hospitals. … The reality in public hospitals is that our systems are not terribly well designed to consistently give … Most of the initial work in patient safety was in hospitals. … In the pursuit of maximizing quality, though, particularly in the public hospital context, we may be

3563. Team Training: Classroom Training vs. High-Fidelity Simulation | PSNet
      psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
      January 12, 2011 - In the companion article, Dr. … real time and in the environment in which they are needed. … in the clinical arena. … In: Advances in Patient Safety: From Research to Implementation. Volumes 1-4. … U.S. hospitals.

3564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50756/psn-pdf
      December 18, 2019 - The responsibility to provide education falls on both the prescriber and the dispensing pharmacist. … an effort to decrease alert fatigue by suppressing low priority alerts in the EHR.11 In this case, … could also be observed in high-risk patients on long-term prescription opioids in outpatient settings … and level of involvement in relation to type 2 diabetes mellitus. … Drug—drug interactions that should be non-interruptive in order to reduce alert fatigue in electronic

3565. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33712/psn-pdf
      June 01, 2011 - In Conversation with… Edward Tenner, PhD June 1, 2011 In Conversation with… Edward Tenner, PhD. … In fact that risk was used in the 19th century to oppose safety signals on railroads. … The worst aviation disaster in history, at the Tenerife airport in the Canary Islands in 1987, occurred … 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.

3566. In Conversation With… David Juurlink, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
      May 22, 2017 - It describes a database-drudging exercise at a Boston hospital that cannot possibly show the risk of … movement really begins in earnest in around 2000. … Delirium, falls, fractures, subdurals, testosterone suppression, motor vehicle collisions. … June 25, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical … December 21, 2016 View More See More About The Topic Hospitals Facility

3567. In Conversation With… Sharon K. Inouye, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
      December 01, 2012 - RW : When we see people in the hospital with delirium, what are the major errors that you see in workup … the hospital setting is recognized while that patient is in the hospital. … If you believe that many cases of delirium are caused by things that we do to patients in hospitals and … the thousands of hospitals. … Our estimates weren't in even every hospital but just the hospitals that would be willing to do it.

3568. In Conversation With... Libby Hoy and Stephen Hoy | PSNet
      psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
      March 10, 2021 - Services (CMS), AIR, and small rural and critical access hospitals out here in California. … CMS mandated patient family engagement in the QIOs and in the Partnership for Patients (PfP) and Hospital … into the hospital that they would be active participants in care. … It looks different in end-stage renal disease programs, in primary care, it looks different in the hospital … primary care , during care transitions , and in hospital settings .

3569. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837784/psn-pdf
      August 05, 2022 - I am an assistant professor in cardiology at Johns Hopkins Hospital. … attack, and about 75% of those hospital readmissions are preventable. … and check whether it made any difference in hospital readmissions? … We conducted the MiCORE study across four hospitals: Johns Hopkins Hospital, Johns Hopkins Bayview Medical … Center, Massachusetts General Hospital, and Reading Health.

3570. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet
      psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
      November 25, 2020 - Patients should lie supine during the exam to avoid vasovagal reactions that could lead to falls and … Hand and wrist tendons may be repaired in the ED or later in the ambulatory setting. … depends on the location and extent of the injury, the clinical setting (e.g., academic versus rural hospital … Extensor and flexor tendon injuries in the hand, wrist, and foot. In: Roberts JR, Hedges JR, eds. … September 29, 2021 WebM&M Cases EMS Perils from Hospital

3571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857059/psn-pdf
      November 29, 2023 - 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 … Falling through the cracks: information breakdowns in critical care handoff communication. … Opportunities to improve clinical summaries for patients at hospital discharge.

3572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60611/psn-pdf
      June 24, 2020 - femoral-femoral bypasses in September 2018 presented to the hospital 4 months later with right calf … The prescription and written instructions on the After-Hospital Summary (AHS) were correct, but nurse-generated …  completing clinical work.15   Prescriptions sent to retail pharmacies from hospitals at discharge or … this type of program also reinforces the education they were provided in the hospital and gives them … “Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.”

3573. The Role of Health Literacy in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
      March 22, 2009 - at public hospitals. … The reality in public hospitals is that our systems are not terribly well designed to consistently give … Most of the initial work in patient safety was in hospitals. … In the pursuit of maximizing quality, though, particularly in the public hospital context, we may be … The overlap between health literacy and patient safety has gotten me in the room to talk to hospital

3574. Do Not Disturb! | PSNet
      psnet.ahrq.gov/web-mm/do-not-disturb
      February 03, 2011 - shaking but quickly falling asleep when the stimulus ceased. … action than in remediation. … "( 5 ) An investment in education in professionalism and in physician self-care can help prevent a lifetime … of subsequent problems in some cases. … Topic Hospitals Health Care Providers Health Care Executives and Administrators Organizational

3575. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing | PSNet
      psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
      August 21, 2005 -  completing clinical work. 15    Prescriptions sent to retail pharmacies from hospitals at discharge … this type of program also reinforces the education they were provided in the hospital and gives them … “Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.” … hospitals: a systematic review. … hospitals through a systems approach and technological innovation: a prescription for 2010.

3576. Intubation Mishap | PSNet
      psnet.ahrq.gov/web-mm/intubation-mishap
      April 26, 2023 - If efficacy can be established, dissemination models like these should prove useful for hospitals and … Using simulation in the PICU at the Children’s Hospital at Dartmouth, we closely emulated this case in … Professor of Anesthesiology and OB/GYN, Dartmouth College of Medicine Staff Anesthesiologist, Children’s Hospital … Acute Hospital Care Units April 26, 2023 Ergonomic and human factors affecting … View More See More About The Topic Intensive Care Units Children's Hospitals

3577. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
      January 01, 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 … administrations which included inadequate monitoring in a staggering 29% of cases … In: Bradley WG, Daroff RB, Fenichel G, Jankovic J (eds). … In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021.

3578. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet
      psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
      September 01, 2007 - Attarian, written communication, November 2017) In addition, administrative notifications abound in the … Teamwork plays a key role in ambulatory test result management. … Issues and initiatives in the testing process in primary care physician offices. … February 24, 2011 How many hospital pharmacy medication dispensing errors go undetected … U.S. hospitals.

3579. In Conversation With… Shantanu Agrawal, MD, MPhil | PSNet
      psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
      February 26, 2025 - , and particularly in patient safety. … in its uses? … RW : When NQF started, probably 5% of hospitals had electronic health records, and now 5% do not. … There are more than 5000 hospitals and health systems around the country and many, many more physician … We've done some work in the last couple of years taking steps in this direction.

3580. Near Miss with Bedside Medications | PSNet
      psnet.ahrq.gov/web-mm/near-miss-bedside-medications
      February 01, 2006 - Different definitions are in use, which are related to two factors in describing the "near miss-ness" … In fact, capturing every adverse event or near miss can be overwhelming and may be undesirable, as in … In this case, the patient safety committee of the hospital proposed that three actions be taken. … In this case, this might involve an audit to be conducted in 6 months that determines if the specified … In conclusion, there is great power in capturing close calls as a way to improve patient safety.