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3661. Diagnosis and diagnostic errors: time for a new paradigm. | PSNet
      psnet.ahrq.gov/issue/diagnosis-and-diagnostic-errors-time-new-paradigm
      March 09, 2022 - health records at hospitals and ambulatory sites. … May 15, 2013 Impact of vendor computerized physician order entry in community hospitals … January 28, 2015 Medication-related harm in older adults following hospital discharge … December 1, 2021 Lessons learned from a national hospital antibiotic stewardship implementation … Acute Hospital Care Units April 26, 2023 Perspectives on Safety

3662. Complaints as Safety Surveillance | PSNet
      psnet.ahrq.gov/web-mm/complaints-safety-surveillance
      May 05, 2021 - She was admitted to the hospital and given intravenous fluids and intravenous hydromorphone (Dilaudid … None of those patients had clearly experienced an adverse event, but the hospital faced a decision about … A Different Kind of System Problem In our experience, most hospital-based practitioners admit that … Speaking up for patient safety by hospital-based health care professionals: a literature review. … September 6, 2016 Families as partners in hospital error and adverse event surveillance

3663. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
      psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
      October 01, 2004 - established to encourage hospitals to voluntarily collect and report hospital quality performance information … .( 2 ) All acute care hospitals in the United States have been invited to participate in this initiative … Wisconsin found that hospitals involved in public reporting of risk-adjusted outcomes engaged in more … subscribers access to data that compare hospitals in a region. … Care in U.S. hospitals—the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-274.

3664. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet
      psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
      September 25, 2019 - an 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 … Overdose August 21, 2005 View More See More About The Topic Hospitals

3665. Communication Failure—Who's in Charge? | PSNet
      psnet.ahrq.gov/web-mm/communication-failure-whos-charge
      April 01, 2018 - throughout the night, neither of them recognized a need to go to the hospital to evaluate the child. … 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. … Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital

3666. In Conversation With... Francoise Marvel, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
      August 05, 2022 - I am an assistant professor in cardiology at Johns Hopkins Hospital. … 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. … Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18,

3667. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836839/psn-pdf
      March 31, 2022 - errors is more robust in higher performing hospitals where clinicians feel more psychologically safe … relative to clinicians in lower performing hospitals. … A study of a regional hospital system using a deidentified dataset derived from the Hospital Survey … In 2019, AHRQ released a new version, the SOPS® Hospital Survey 2.0. … https://www.ahrq.gov/sops/surveys/hospital/index.html 6.

3668. In Conversation with...Albert Wu, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
      February 26, 2025 - What ideally would have been done was that someone at a higher level than the individual hospital would … Most hospitals in the United States do several root cause analyses a year, and there is not an indigestible … At every meeting of a hospital board, it would be reasonable to present the sentinel events and the root … In most hospitals, the difference between it never happening again and happening once is not statistically … hospitals and hospital systems, where they exist, should track what's going on.

3669. 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

3670. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852700/psn-pdf
      August 30, 2023 - In Conversation with... … In Conversation with.. … increases in pressure ulcers and falls. … For example, a recent study using 2018 data showed that preventable harms were very common in 11 hospitals … performance measures are associated with measuring and reporting specific harms, such as an infection, falls

3671. 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.

3672. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49846/psn-pdf
      November 01, 2018 - The Case A 65-year-old man was admitted with head and spine trauma after falling from a tree while doing … Given the patient's critical condition, hospital policy dictated that he be accompanied by a nurse and … The Commentary Commentary by Olle ten Cate, PhD Adequate supervision is necessary in teaching hospitals … Patients cared for in teaching hospitals should expect to receive safe and high-quality care. … A trainee in a clinical rotation at a teaching hospital should expect to receive high-quality guidance

3673. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836941/psn-pdf
      April 27, 2022 - Home-based care programs can accept patients discharged from hospitals either in their home or an assisted … functionally frail patients who are also at higher risk for patient safety events such as medication errors, falls … or mortality.24 Patients discharged from hospitals to HHA care have accounted for 25% of hospital readmissions … Hospital at home versus in-patient hospital care.?Cochrane Database Syst Rev. 2005;(3):CD000356. … Hospital-at-Home interventions vs in-hospital stay for patients with chronic disease who present to

3674. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-457
      September 25, 2024 - Set at one pediatric hospital in Australia, this retrospective study evaluated technology-related prescribing … After an adverse event, the way hospitals involve families plays a significant role in the families' … Book/Report Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 … AHRQ Publication no. 24-0084 In-hospital adverse events provide a window … hospital stay, a reduction from 7.1% in 2021.

3675. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49804/psn-pdf
      September 01, 2017 - for more than 500,000 hospital admissions and 10,000 inpatient deaths annually. … In-hospital deaths were rare, occurring in only 0.3% of admissions.(1) However, brisk gastrointestinal … The presence of blood clots in the stool decreases the likelihood of upper GIB.(9) However, in some … In addition, most of the patients included in studies of restrictive transfusion thresholds had upper … A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper

3676. 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

3677. The Impact of Communication on Medication Errors | PSNet
      psnet.ahrq.gov/web-mm/impact-communication-medication-errors
      August 01, 2009 - He had been followed by an anticoagulation clinic at his local hospital for several years. … Bleeding-related hospital admissions and 30-day readmissions in patients with non-valvular atrial fibrillation … “Hospital-Based Medication Reconciliation Practices: A Systematic Review.” … August 1, 2009 WebM&M Cases A Tale of Two Falls … August 1, 2006 View More See More About The Topic Hospitals

3678. 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

3679. 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

3680. Are We Getting Better at Measuring Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
      November 10, 2015 - Validation of Hospital Administrative Dataset for adverse event screening. … Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;266:2847-2851. … A national profile of patient safety in U.S. hospitals. Health Aff (Millwood). 2003;22:154-166. … five Veterans Health Administration (VHA) hospitals. … performance and financial penalties in Veterans Health Administration hospitals?