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3821. In Conversation With… Rebecca Lawton, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
      March 24, 2025 - At the time, British Rail had a problem in that about one in a thousand shunters were dying every year … RW : In terms of what you eventually ended up applying in patient safety, what were the general lessons … RW : In some ways, you've demonstrated that making change in complex organizations is hard. … Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, … , MPH September 1, 2007 View More See More About The Topic Hospitals

3822. Weighing In on Surgical Safety | PSNet
      psnet.ahrq.gov/web-mm/weighing-surgical-safety
      August 04, 2021 - in functional capacity. … Richard's Hospital Chichester, UK   Faculty Disclosure: Dr. Brodsky and Dr. … a children's hospital. … multistate hospital network--13 academic medical centers, April-June 2020. … Hygiene Compliance May 1, 2014 A case for safety leadership team training of hospital

3823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Part of this commentary is based on my experience as a physician in Vietnam in the 1960s and 34 years … In a systematic review of 7000 refugees, PTSD was found in 9% and major depression in 5%, with considerable … comorbidity.(4) In a study in Australia, long-term Vietnamese refugees had a prevalence rate of PTSD … There are several important changes clinics and hospitals can make to address the needs of refugee patients … In: Okparu SO, ed. Clinical Methods in Transcultural Psychiatry.

3824. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
      January 01, 2022 - A study in King’s College Hospital found 31% of patients were determined to lack mental capacity, and … similar studies in general hospitals have found 9-52% of patients lacked mental capacity1. … would result in small or no improvements in clinical outcomes … from families and/or caregivers in order to avoid an omission in care. … There is a major gap in access to palliative care outside the hospital, and it is not uncommon for these

3825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73906/psn-pdf
      October 06, 2021 - ’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

3826. Robotic Surgery: Risks vs. Rewards | PSNet
      psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
      October 31, 2023 - The patient ultimately required several additional surgeries and a prolonged hospital stay. … The purported benefits of RAS also include smaller incisions, decreased blood loss, shorter hospital … Their results supported previous findings of lower transfusion rates, shorter hospital stays, similar … developing field.( 17,20,24 ) Until well-validated credentialing and training models can be developed, hospitals … ever reported to the FDA.( 21-23 ) There needs to be a more rigorous reporting effort by individual hospitals

3827. In Conversation With... Libby Hoy and Stephen Hoy | PSNet
      psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
      March 10, 2021 - Services (CMS), AIR, and small rural and critical access hospitals out here in California. … CMS mandated patient family engagement in the QIOs and in the Partnership for Patients (PfP) and Hospital … into the hospital that they would be active participants in care. … It looks different in end-stage renal disease programs, in primary care, it looks different in the hospital … primary care , during care transitions , and in hospital settings .

3828. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet
      psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
      December 01, 2012 - 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 and … the thousands of hospitals. … Our estimates weren't in even every hospital but just the hospitals that would be willing to do it. … hospitals.

3829. The Role of Health Literacy in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
      March 22, 2009 - 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 … The overlap between health literacy and patient safety has gotten me in the room to talk to hospital

3830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837784/psn-pdf
      August 05, 2022 - I am an assistant professor in cardiology at Johns Hopkins Hospital. … attack, and about 75% of those hospital readmissions are preventable. … 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.

3831. Removing Insult from Injury—Disclosing Adverse Events | PSNet
      psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
      February 01, 2006 - patient to receive information about clinically relevant medical errors," and that "the Johns Hopkins Hospital … event.( 10 ) It opens with one mother describing the tragic death of her baby daughter at Johns Hopkins Hospital … Hospital disclosure practices: results of a national survey. … But an error occurred when your Mom was here at the hospital last week." … And he looked at me and he said, "I'm the head of legal counsel here at this hospital, and everything

3832. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
      January 01, 2021 - – In the previous 365 days, she had spent 199 days hospitalized (54% of the year) at one hospital … – She received oxycodone at 180-240 OME during this hospital stay and was discharged with instructions … – The data in PDMPs are state-specific and various settings/organizations in addition to hospitals … National Patient Safety Goals® Effective January 2021 for the Hospital Program. … Society of Hospital Medicine. Best Possible Medication History (BPMH) Train the Trainer Materials.

3833. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing | PSNet
      psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
      August 21, 2005 -  completing clinical work. 15    Prescriptions sent to retail pharmacies from hospitals at discharge … this type of program also reinforces the education they were provided in the hospital and gives them … “Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.” … hospitals: a systematic review. … hospitals through a systems approach and technological innovation: a prescription for 2010.

3834. Meaningful Measurement in Patient and Family Engagement | PSNet
      psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
      March 10, 2021 - primary care , during care transitions , and in hospital settings . … Services (CMS), AIR, and small rural and critical access hospitals out here in California. … CMS mandated patient family engagement in the QIOs and in the Partnership for Patients (PfP) and Hospital … into the hospital that they would be active participants in care. … It looks different in end-stage renal disease programs, in primary care, it looks different in the hospital

3835. In Conversation With… Robert M. Wachter, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
      August 01, 2015 - 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 … 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. … , MPH September 1, 2007 View More See More About The Topic Hospitals

3836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60611/psn-pdf
      June 24, 2020 - femoral-femoral bypasses in September 2018 presented to the hospital 4 months later with right calf … The prescription and written instructions on the After-Hospital Summary (AHS) were correct, but nurse-generated …  completing clinical work. 15    Prescriptions sent to retail pharmacies from hospitals at discharge … this type of program also reinforces the education they were provided in the hospital and gives them … “Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.”

3837. Can Research Help Us Improve the Medical Liability System? | PSNet
      psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
      March 01, 2012 - The error is intercepted by the hospital pharmacist before the medication is scheduled to be administered … Allen Kachalia, MD, JD Associate Chief Quality OfficerBrigham & Women's Hospital References   … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … How does the brand new risk manager at a 150-bed community hospital in Ypsilanti get this work done? … July 8, 2020 Inpatient Notes: mistakes in the hospital—communicating, apologizing, and

3838. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - How does the brand new risk manager at a 150-bed community hospital in Ypsilanti get this work done? … The error is intercepted by the hospital pharmacist before the medication is scheduled to be administered … Allen Kachalia, MD, JD Associate Chief Quality OfficerBrigham & Women's Hospital References   … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … September 21, 2005 View More See More About The Topic Hospitals Health

3839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73104/psn-pdf
      January 04, 2021 - Healthcare providers and hospitals have observed a decline in patients seeking emergency care for serious … COVID-19 in a hospital setting, it is very rare for patients to develop hospital-acquired COVID-19 … Surge planning has become even more important for hospital operations in an effort to take into consideration … 'I'm smiling under here': Masks, plexiglass and questions the norm as hospitals lure patients back in … Patient safety concerns in COVID-19–related events: a study of 343 event reports from 71 hospitals in

3840. Hold the tPA | PSNet
      psnet.ahrq.gov/web-mm/hold-tpa
      July 29, 2020 - In order to expedite treatment (crucial because research finds benefit for thrombolysis in acute stroke … However, in the rush to administer the tPA in the 3-hour time window, she was given the tPA before her … the community—in more than 50% of patients treated in some early series.( 2,5,6 ) When examined in a … associated with increased in-hospital mortality.( 2 ) The most common protocol deviations were treatment … Thrombolysis for acute stroke in routine clinical practice.