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3761. The Safety of Medical Devices | PSNet
      psnet.ahrq.gov/perspective/safety-medical-devices
      June 01, 2011 - Warranty and USFDA approval concerns precluded the hospital from modifying the equipment. … The hospital developed a report of the event for the manufacturer. … Letters: How to reduce tube mix-ups in hospitals. New York Times. August 25, 2010:A26. 7. … 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.

3762. In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 | PSNet
      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

3763. Too Many Cooks in the Kitchen | PSNet
      psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
      March 07, 2018 - While being assisted to a standing position on hospital day 13, the patient’s left leg buckled and he … , venous thromboembolism and  hospital acquired-infection . 8  Pneumonia leading to sepsis and organ … 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 … Comparison of Early Warning Scoring Systems for Hospitalized Patients With and Without Infection at Risk for In-Hospital

3764. Shortcuts to Acetaminophen-induced Liver Failure | PSNet
      psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
      July 01, 2017 - 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 … of Ob/Gyn Division of Maternal–Fetal Medicine University of Rochester Medical Center/Strong Memorial Hospital … in rats in vivo. … a multistate hospital network--13 academic medical centers, April-June 2020.

3765. Pocket Syringe Swap | PSNet
      psnet.ahrq.gov/web-mm/pocket-syringe-swap
      July 01, 2006 - 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 … drug safety in anesthesia. … Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. … Developing a Successful Hospital Safety Program July 1, 2006 WebM

3766. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
      psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
      November 27, 2019 - alcohol use disorder, and cirrhosis of the liver was brought into the emergency department (ED) after falling … Pre-hospital personnel attempted to control the bleeding using a tourniquet. … In the OR, blood was found in the peritoneal space. … the hospital. … Regional trauma systems have been established to triage patients of this type to hospitals (i.e., trauma

3767. 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

3768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49704/psn-pdf
      March 01, 2014 - clinicians now recognized that the infant had active Rh hemolytic disease, and he was admitted to the hospital … , which causes benign, mild jaundice in adults and can contribute to elevated bilirubin levels in newborns … enterohepatic circulation, in which bilirubin that has been conjugated in the liver is unconjugated … In addition, although it is common in patient safety discussions to focus on errors of omission (9), … Second, there appears to have been a sudden increase in hemolysis or decrease in bone marrow compensation

3769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49782/psn-pdf
      January 01, 2017 - 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

3770. Looking for Meds in All the Wrong Places | PSNet
      psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
      June 16, 2021 - Looking for Meds in All the Wrong Places Citation Text: Manias E. … Looking for Meds in All the Wrong Places. PSNet [internet]. … Looking for Meds in All the Wrong Places. PSNet [internet]. … hospital medication safety behaviours. … hospital.

3771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49591/psn-pdf
      October 01, 2009 - 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. … Safety and quality innovations that were incorporated into our daily hospital operations (eg, rapid

3772. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia | PSNet
      psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
      February 23, 2022 - In patients in this state, administering solute via either isotonic or hypertonic saline leads to rapid … In 2013, an American panel of experts in hyponatremia developed additional guidance on hyponatremia treatment … dramatic overcorrection of serum sodium (>20 mEq/L) in the initial two-hour interval. … January 10, 2018 Hospital quality and patient safety competencies: development, description … Intensive Care Units Physicians Nurse Managers Quality and Safety Professionals Hospital

3773. Production Pressures | PSNet
      psnet.ahrq.gov/web-mm/production-pressures
      November 16, 2022 - A second anesthesiologist in the group spends the day in the operating room (OR) supervising three nurse … Very often, changes in workload occur in health care in an unpredictable manner. … such days—for example, could an anesthesiologist be pulled from a critical care unit or an affiliated hospital … January 20, 2021 Information flow during pediatric trauma care transitions: things falling … 'Zebra' January 1, 2006 View More See More About The Topic Hospitals

3774. Implementing a Patient Safety Program at a Large National Health System | PSNet
      psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
      January 01, 2008 - The AHS hospitals are located in ten states. … In addition, individual hospitals have presented their experiences and outcomes from their work in a … In addition to 100% hospital participation in the IHI campaign, the Office of Clinical Effectiveness … In the system I'm in now, there are so many capable resources at both the community hospitals and the … But it resulted in a dramatic decrease in hospital-associated infections.

3775. In Conversation with...James L. Reinertsen, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
      August 01, 2007 - In the case of hospitals, they represent the community and the people who live in it—and they're there … So when they read in the paper that 50,000 to 100,000 people were being killed in hospitals each year … but not in our hospital." … your hospital?" … July 19, 2016 Hospital patient safety: characteristics of best-performing hospitals.

3776. Medication Handling and Compounding Errors in the Operating Room. | PSNet
      psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
      May 16, 2022 - the hospital. 1-3 Medication errors not only lead to potential patient harm and longer hospital stays … classification of the preparation from reconstitution to compounding. 8,9 This type of compounding falls … Board of Pharmacy and by a national standard known as US Pharmacopeia (USP) Chapter <797>. 9,10 , 17  Hospital … the perioperative setting; however, all are required for sterile compounding in a hospital pharmacy … Hospitals must verify whether compounding is included in the nurses’ scope of practice as it is not allowed

3777. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-291
      May 26, 2021 - Nurse managers play a key role in implementing strategies at the nursing and hospital level. … Three hospitals in one health system implemented a voluntary error reporting system for clinicians to … Nurse managers play a key role in implementing strategies at the nursing and hospital level. … for several weeks, resulting in hyponatremia and unnecessary hospital admission. … EMS at Christian Hospital in North St.

3778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846126/psn-pdf
      March 09, 2023 - the hospital.1-3 Medication errors not only lead to potential patient harm and longer hospital stays … classification of the preparation from reconstitution to compounding.8,9 This type of compounding falls … Board of Pharmacy and by a national standard known as US Pharmacopeia (USP) Chapter <797>.9,10,17  Hospital … the perioperative setting; however, all are required for sterile compounding in a hospital pharmacy … Hospitals must verify whether compounding is included in the nurses’ scope of practice as it is not

3779. 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

3780. 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.