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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - year-old woman presented to the Emergency Department (ED) for evaluation of “altered mental
status” after falling … Depending on the culture and practices in the hospital, nursing
staff should expect either a brief physician … hospitals.19
One approach to improving handoffs between medical professionals involves using a standardized … at 9 different
hospitals.20 I-PASS is a handoff program that trains medical professionals to synthesize … Anita Singh, MD
Department of Internal Medicine
Division of Hospital Medicine
UC Davis Medical Center
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - laboratory results (or
other key patient data) often depends on whether this test was part of the patient's hospital … medical record
and whether his primary care doctor used the hospital laboratory for blood tests. … If the primary care doctor was community based, and not part of
hospital-based practice at the site … In another study at Brigham and
Women's Hospital in Boston, 565 of 5083 patients seen in a preoperative … In: Hilditch
WG, Asbury AJ, Jack E, McGrane S.
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - laboratory results (or other key patient data) often depends on whether this test was part of the patient's hospital … medical record and whether his primary care doctor used the hospital laboratory for blood tests. … If the primary care doctor was community based, and not part of hospital-based practice at the site where … Communication in the preoperative setting is particularly challenging when physicians practice in different … In another study at Brigham and Women's Hospital in Boston, 565 of 5083 patients seen in a preoperative
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Michael’s Hospital; Toronto General Hospital; University of Pittsburgh Medical Center Health Plan; Indiana … Center; Geisinger Health System; Penn Medicine; Duke University Health System; New York City Health & Hospitals … ; Yale New Haven Health; Dartmouth-Hitchcock; Brigham and Women’s Hospital. … Getting Started with This Innovation
Get the health system or hospital leadership’s support. … May 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - If you’re looking at rates of infection in a hospital over a period of time, moving the needle on those … to a lack of timely language assistance include performing an x-ray on the wrong part of the body, falls … Language proficiency and adverse events in US hospitals: a pilot study. … A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. … https://www.ahrq.gov/health-literacy/systems/hospital/lepguide/index.html .
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - The vials, in the three sizes used to make the admixtures, are all
contained in the same Pyxis drawer … 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.
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - 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
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psnet.ahrq.gov/node/33742/psn-pdf
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 … given
the thousands of hospitals. … Our estimates weren't in even every hospital but just the hospitals that would be willing to do it.
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psnet.ahrq.gov/periodic-issue/periodic-issue-349
July 08, 2022 - Study
Distinguishing high-performing from low-performing hospitals for severe maternal … the hospital can lead to differential treatment. … the hospital can lead to differential treatment. … Combining patient complaints and staff incident reports allows hospitals to better understand causes … , and passed away three weeks later at the hospital.
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - technically a voluntary process, board certification is now required for employment and credentialing by most hospitals … the hospital setting (called the focused practice in hospital medicine program ).( 12 ) In addition … I believe the professional organizations, from medical practices to hospital to medical societies and … Hospital medicine, focused practice. [Available at]
13. Epstein RM, Siegel DJ, Silberman J. … July 31, 2023
Patient Safety Innovations
Preventing Falls
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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
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psnet.ahrq.gov/periodic-issue/periodic-issue-374
December 14, 2022 - This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. … three hospitals. … or hospital admissions). … Review
Addressing patient safety hazards using critical incident reporting in hospitals … This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals.
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - DB: Well, in particular, it's not to the advantage of hospitals today to improve quality or safety. … DB: It depends a lot on what the hospital already has in place and what their resources are. … However, I think it has a lot of benefits and most hospitals will, in the not too distant future, want … If my parents called me and said that they need to go to a
hospital in their community, and they want … The best evidence comes from hospitals. Another is
barcoding.
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - I think it's good for CMS to try to hold hospitals accountable for some of these things. … A better structural measure could direct hospitals to set a goal for year-over-year improvement in the … Sarah Mossburg: You’ve talked about the importance of incremental goals that hospitals have the means … reporting, and decreases in preventable harm: 39% decrease in injuries with falls, 37% fewer pressure … Indeed, the amount of effort expended in the resource scarce environment of hospital administration suggests
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psnet.ahrq.gov/node/49468/psn-pdf
December 16, 2004 - How—in the world's most sophisticated operating
theaters and in the hands of highly trained surgeons—can … Or, in this case, almost
happen? … On the surface, the problem in this case is that the "Time Out" provision in the Universal Protocol was … recovery room, multiple, seemingly simple processes—involving doctors,
nurses, technicians, and other hospital … taught in these
schools.
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - Later in the hospital course, he required abscess drainage by an interventional radiologist. … a multistate hospital network--13 academic medical centers, April-June 2020. … September 23, 2020
A national profile of patient safety in U.S. hospitals. … safety score for US hospitals. … May 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/49638/psn-pdf
January 01, 2012 - throughout the night, neither of
them recognized a need to go to the hospital to evaluate the child … So in this case the issue of who was "in charge" is quite real. … When, as in this case, data falls outside what the mental model predicts or therapy does not
produce … Adequacy of information transferred at
resident sign-out (in-hospital handover of care): a prospective … Trends in hospital volume and operative mortality for high-risk
surgery.
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Therapeutic effects are realized in 7 to 10 days, peak in 4 to 6 weeks, and diminish by 12 weeks. … the foot or the abductor digiti minimi in the hand) before diagnosing therapeutic resistance.( 1 ) In … Management Royal Hallamshire Hospital United Kingdom References 1. … August 16, 2023
Patient falls in the operating room setting: an analysis of reported … Acute Hospital Care Units
April 26, 2023
Perspectives on Safety
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - that of other CVCs. 2 , 15 The increased risk to inpatients highlights the need for vigilance by hospital … Patient Education Lengths of stay in hospitals have decreased steadily over the past 40 years. 19 Increasing … hospital practice: factors associated with turnover, outcomes, and patient safety. … Related Resources
Patient Safety Innovations
Preventing Falls … Appendicitis
June 1, 2003
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See More About The Topic
Hospitals
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - in her left low back. … In 2020, as the COVID-19 pandemic restricted in-person visits, she was seen by video twice for progressive … In this case, this rupture likely further exacerbated the delay in diagnosis. … March 23, 2012
Older patients' engagement in hospital medication safety behaviours. … June 16, 2021
Medication reconciliation at hospital discharge: a qualitative exploration