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3801. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - 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 have … Falling through the cracks: information breakdowns in critical care handoff communication. … Opportunities to improve clinical summaries for patients at hospital discharge.

3802. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? | PSNet
      psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
      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.

3803. In Conversation with...James P. Bagian, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
      September 01, 2006 - is that safety folks from more than 100 non-VA hospital systems in the US have come to us to be trained … RW: In a practical sense, let's say I'm in a VA hospital in Des Moines and I'm newly hired to run the … efforts include increasing disclosure of adverse events; root cause analyses; and programs for preventing falls … VA has installed bar-coded medication administration (BCMA) in nearly all hospitals, and most clinicians … Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-274.

3804. Beyond the Hospital: the New Frontier of Patient Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
      August 01, 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. … RW : In the hospital there are significant pressures and drivers that create a business case to invest

3805. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
      September 24, 2024 - reporting, and decreases in preventable harm: 39% decrease in injuries with falls, 37% fewer pressure … notes that, since the 2013 launch of their Certified Zero Harm Awards, member hospitals have achieved … Indeed, the amount of effort expended in the resource scarce environment of hospital administration suggests … 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

3806. In Conversation with…David W. Bates, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
      May 01, 2018 - 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.

3807. The Deadly Duo | PSNet
      psnet.ahrq.gov/web-mm/deadly-duo
      April 28, 2021 - May 5, 2014 The effects of hospital-physician financial integration on adverse incident … the Children's Hospitals' Solutions for Patient Safety Collaborative. … March 20, 2019 Resource-based view on safety culture's influence on hospital performance … : a study of U.S. hospitals. … October 27, 2021 Speaking up about patient safety in psychiatric hospitals - a cross-sectional

3808. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - • A few hours later, the clinic surgeon further reviewed the prior hospital record and noted the … are under-read because the primary inquiry was satisfied. 25 PEG Tube Complications (4) • Most hospitals … to enhance radiologists’ performance. – An online survey of 339 institutions including 61 teaching hospitals … Falling through the cracks: information breakdowns in critical care handoff communication. … Opportunities to improve clinical summaries for patients at hospital discharge.

3809. In Conversation With… Eduardo Salas, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
      November 01, 2011 - So, I spent a lot of my time writing and giving talks in schools of medicine and hospitals about this … I found leadership in hospitals or in schools of medicine didn't know what to do with this concept at … to health care in America and in many other places for that matter. … But a lot of hospitals call me for what you just asked me. … Reducing falls and fall-related injuries in the VA system. J Healthc Saf Q. 2003;1:25-33. 8.

3810. 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

3811. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
      psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
      November 27, 2019 - procedure, the patient experienced bradycardia and cardiac arrest within 9 hours of admission to the hospital … soft tissue necrosis), cardiac dysrhythmia, extravasation, acute kidney injury, increased duration of hospital … In this case, norepinephrine was used to achieve higher mean arterial pressure (MAP) goals in an attempt … complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital … in 38 countries (PRICOV-19).

3812. In Conversation With… Susan E. Skochelak, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
      February 01, 2019 - In Conversation With… Susan E. … Things do have to be removed in order to put new material in. … RW : Our main academic hospital becomes more tertiary and quaternary every day, and we're partnering … some areas such as hospital-acquired infections.( 3,4 ) However, the magnitude of improvement has not … of these patient safety concerns, many studies have suggested the United States health care system falls

3813. New Insights on Safety and Health IT | PSNet
      psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
      August 01, 2015 - If a second report was released next week, where do you see health IT falling in the pecking order relative … 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. … hospitals through a systems approach and technological innovation: a prescription for 2010. … January 12, 2011 View More See More About The Topic Hospitals Health

3814. In Conversation With... José A, Morfín, MD, FASN | PSNet
      psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
      April 28, 2021 - In Conversation With... … I am also the medical director at two of the programs, one in Sacramento and one in Folsom. … KH : It sounds like, between in-home and in-facility dialysis, the concerns are similar. … include infections, hypotension, electrolyte disturbances, blood loss, adverse drug effects, and patient falls … Home Care Nephrology Side Effects/Adverse Drug Reactions Nosocomial Infections Patient Falls

3815. Delayed Breast Cancer Diagnosis: A False Sense of Security. | PSNet
      psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
      May 01, 2005 - feared cancer diagnosis in women. … study by The Doctor’s Company and CRICO, the captive malpractice insurer of the Harvard-affiliated hospitals … the finding before recommending management limited to routine mammography screening.” 12 BI-RADS 3 falls … Schiff, MD Brigham and Women’s Hospital Harvard Medical School Ted James, MD Chief, Breast Surgical … Diagnosis Errors (PRIDE) Learning Network, a collaborative project convened by the Brigham and Women’s Hospital

3816. Video to Improve Patient Safety: Clinical and Educational Uses | PSNet
      psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
      March 01, 2004 - surgery ( 1 ) may mark a new frontier in the use of video in medicine. … Notification that video surveillance occurs in patient care areas is usually included in hospital admission … In one case conference in which video vignettes of trauma patient resuscitation were shown, a senior … in a Level 1 trauma center. … with MRSA April 1, 2008 View More See More About The Topic Hospitals

3817. Delayed Diagnosis of Kidney Transplant Complications | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
      January 29, 2020 - Slow graft function alone, as in the patient in this case, has not traditionally been a factor that prompts … In this case, the patient’s slow graft function in the immediate post-transplant period did not necessitate … Approach to Improving Safety Safety in management of kidney transplant patients in the early post-transplant … Kidney ultrasound is useful tool in posttransplant follow-up. … Castration January 1, 2004 View More See More About The Topic Hospitals

3818. Hiding in Plain Sight | PSNet
      psnet.ahrq.gov/web-mm/hiding-plain-sight
      April 24, 2019 - Hiding in Plain Sight Citation Text: Weinberg JM. Hiding in Plain Sight. … Hiding in Plain Sight. PSNet [internet]. … Background Herpes zoster (or shingles) occurs in approximately 1 million people annually in the United … Hiding in Plain Sight. PSNet [internet]. … April 24, 2019 An inpatient fall prevention initiative in a tertiary care hospital.

3819. A Potent Medication Administered in a Not So Viable Route | PSNet
      psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
      July 20, 2016 - 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

3820. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73229/psn-pdf
      May 26, 2021 - procedure, the patient experienced bradycardia and cardiac arrest within 9 hours of admission to the hospital … soft tissue necrosis), cardiac dysrhythmia, extravasation, acute kidney injury, increased duration of hospital … In this case, norepinephrine was used to achieve higher mean arterial pressure (MAP) goals in an attempt … In patients experiencing shock, weight is an insignificant factor in dosing norepinephrine, as catecholamine … is a critical factor as in pediatrics.8   The disadvantage of non-weight-based dosing in this population