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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - While being assisted to a standing position on hospital day 13, the patient’s left leg buckled and he … Due to limited operating room availability, his hip operation
on hospital day 24 began at 16:00 and … 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 … of Early Warning Scoring Systems for Hospitalized
Patients With and Without Infection at Risk for In-Hospital
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - in one patient, such as the patient in this case. … Courts will usually respect a medical decision if a rationale that falls within a reasonable range of … 2023
Information handoff and outcomes of critically ill patients transferred between hospitals … to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital … Related Resources
WebM&M Cases
Walking Out of a Hospital
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - in every hospital that has a cardiac catheterization laboratory; transfer to a regional center is often … who present to rural or safety net hospitals with limited capabilities. … , the cardioversion shock must be synchronized with the ECG to prevent the shock from inadvertently falling … to hospitals with and without revascularization services. … Audit of defibrillators at an urban public sector hospital.
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - to in the US? … A colleague who was former Minister of Health in Uganda said to me, "We
cannot tell people that hospitals … RW: One thing we confront working at a large health system is that it has big hospitals and little hospitals … preventing surgical site infection in African hospitals. … Every new
hospital that they opened would start with discussions from the patients that were going to
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - woman with metastatic breast cancer recently treated with immunosuppressive therapy
presented to the hospital … A later review revealed that the hospital microbiology laboratory was aware of the microbiology result … Clinical and economic impact of contaminated blood
cultures within the hospital setting. … Empirical antimicrobial prescriptions in patients with
Clostridium difficile infection at hospital admission … Patient safety concerns arising from test results that return after
hospital discharge.
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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
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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
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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
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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
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - include infections, hypotension, electrolyte disturbances, blood loss, adverse drug effects, and patient falls … In Conversation With... … KH : It sounds like, between in-home and in-facility dialysis, the concerns are similar. … June 16, 2019
Did hospital engagement networks actually improve care? … Home Care
Nephrology
Side Effects/Adverse Drug Reactions
Nosocomial Infections
Patient Falls
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - In some studies,
an error is counted only if there is identifiable patient harm (3); in others an error … administer, and document
medications without any of the checks and balances routinely employed on hospital … wards and in intensive
care units (ICUs). … drug safety in anesthesia. … Comparison of methods for detecting
medication errors in 36 hospitals and skilled-nursing facilities
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psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - The patient was admitted to the hospital and given broad-spectrum
antibiotics and a diagnosis of "influenza … Bacak, DO, MPH Maternal–Fetal Medicine Specialist Akron Children's Hospital Assistant
Professor of Ob … Ob/Gyn Division of Maternal–Fetal Medicine University of
Rochester Medical Center/Strong Memorial Hospital … Poisoning in pregnancy. In: Foley MR Jr, Strong TH, Garite TJ, eds. … in rats in vivo.
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - The program was initially implemented mainly in hospitals, and later it did spread to other healthcare … hospitals and other care settings, sometimes in response to a patient harm, and other times because … It is easy to talk about how communication should happen, for example, in a surgery unit in a hospital … Aside from training large medical centers and hospitals, a big emphasis will be put on training in various … seen frequently with virtual teams where a diagnosis isn’t communicated quickly enough, or something falls
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - area of the hospital, and may have been under the influence of street drugs. … November 16, 2022
Families as partners in hospital error and adverse event surveillance … a multistate hospital network--13 academic medical centers, April-June 2020. … 30, 2023
Patient Safety Innovations
Preventing Falls … February 6, 2014
View More
See More About The Topic
Hospitals
Health
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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
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See More About The Topic
Hospitals
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - the Interim Chairman of the Department of Medicine at UCSF,
where he also directs the Division of Hospital … 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 … their offices and for hospitals to go through the turmoil and
spend the huge amounts of money to go … Or patients who went to UCSF did better than patients who went to another hospital.
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - the US.( 2 ) Because of these features, EMS serves as the gateway into hospitals for millions with acute … A comparative assessment of adverse event classification in the out-of-hospital setting. … only have 12 minutes between the time you pick them up and get to the hospital to make a difference. … If they walk in the home, just start applying electricity to the chest, take the patient to the hospital … the hospital so that there is a two-way dataflow.
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - provision of equitable care from the outset and offers new insights into traditional outcomes such as hospital … go home and have a headache and have high blood pressure and say, “Well I’m not going back to that hospital … Right as you’re preparing to the leave the hospital, there is so much new information to be aware of, … The hospital is not the place for new things, it’s for tailoring and for going in-depth and for processing … For example, systematically examining the process of care from the patient’s entry point into the hospital
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - what’s normal and who to ask if she's not sure, and that she feels like she’d want to come back to the hospital … go home and have a headache and have high blood pressure and say, “Well I’m not going back to that hospital … Right as you’re preparing to the leave the hospital, there is so much new information to be aware of, … The hospital is not the place for new things, it’s for tailoring and for going in-depth and for processing … For example, systematically examining the process of care from the patient’s entry point into the hospital
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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.