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3861. In Conversation with...Patrick Tighe about Artificial Intelligence | PSNet
      psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
      March 27, 2024 - In terms of improving access to care, hospitals are bursting at the seams across the United States right … Perhaps this isn’t terribly dissimilar from hospital pharmacies. … There are pharmacy and therapeutics committees at hospitals continually looking at this information, … in the healthcare setting and can alert staff when a patient falls or a critical checklist step is skipped … Acute Hospital Care Units April 26, 2023 Perspectives on Safety

3862. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60744/psn-pdf
      July 29, 2020 - with a known history of coronary artery disease and ischemic cardiomyopathy, who was admitted to the hospital … In a patient like the one in this case, with known CAD, rising cardiac biomarkers, and a new drop in … Under-treatment: Women are less likely to be treated by a cardiologist during hospital admission for … addition, pilot results from a study on a cardiac “curbside” initiative at Massachusetts General Hospital … in the Atherosclerosis Risk in Communities (ARIC) Study.

3863. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33833/psn-pdf
      May 01, 2017 - In Conversation With… David Juurlink, MD, PhD May 1, 2017 In Conversation With… David Juurlink, MD, … It describes a database-drudging exercise at a Boston hospital that cannot possibly show the risk of … movement really begins in earnest in around 2000. … Delirium, falls, fractures, subdurals, testosterone suppression, motor vehicle collisions. … the US in particular we have seen doctors in some instances abandoning patients and in others just

3864. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49415/psn-pdf
      September 01, 2003 - detailed in Table 2. … simulated sedation exercise, videos demonstrating code reenactments are sent to all 300 providers over the hospital … If efficacy can be established, dissemination models like these should prove useful for hospitals and … Using simulation in the PICU at the Children’s Hospital at Dartmouth, we closely emulated this case in … Professor of Anesthesiology and OB/GYN, Dartmouth College of Medicine Staff Anesthesiologist, Children’s Hospital

3865. Artificial Intelligence and Patient Safety: Promise and Challenges | PSNet
      psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
      March 27, 2024 - in the healthcare setting and can alert staff when a patient falls or a critical checklist step is skipped … In terms of improving access to care, hospitals are bursting at the seams across the United States right … and to better understand health systems as complex dynamic systems to improve patient access to our hospitals … Perhaps this isn’t terribly dissimilar from hospital pharmacies. … There are pharmacy and therapeutics committees at hospitals continually looking at this information,

3866. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
      January 01, 2024 - – TNKase was administered and he was monitored per hospital protocol. 7 Case Details (4) • Thirty … – Similarly, rural hospitals that lack subspecialty coverage benefit from telemedicine services provided … Impacting Accurate Diagnosis (2) • By expanding access to stroke specialists at community and rural hospitals … 27 Laboratory Testing 28 Laboratory Testing (1) • Inherent to this discussion is whether the hospital … However, this modality may not be available in many hospitals given its high cost.

3867. New Insights About Team Training From a Decade of TeamSTEPPS | PSNet
      psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
      February 01, 2017 - from one floor of a hospital to another in a leading academic medical center, drugs would be labeled … It's always been remarkable to me, compared with other or business organizations how hospitals have three … less likely to just show up in the clinic or hospital with an acute condition that could be treated … major urban hospital emergency department. … About The Topic Hospitals Health Care Providers Facility and Group Administrators Medicine

3868. The NSTEMI Curbside Consultation | PSNet
      psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
      August 04, 2021 - with a known history of coronary artery disease and ischemic cardiomyopathy, who was admitted to the hospital … In a patient like the one in this case, with known CAD, rising cardiac biomarkers, and a new drop in … Under-treatment: Women are less likely to be treated by a cardiologist during hospital admission … addition, pilot results from a study on a cardiac “curbside” initiative at Massachusetts General Hospital … Patient Safety Innovations Enhancing Support for Patients’ Social Needs to Reduce Hospital

3869. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33712/psn-pdf
      June 01, 2011 - In Conversation with… Edward Tenner, PhD June 1, 2011 In Conversation with… Edward Tenner, PhD. … In fact that risk was used in the 19th century to oppose safety signals on railroads. … The worst aviation disaster in history, at the Tenerife airport in the Canary Islands in 1987, occurred … 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.

3870. Team Training: Classroom Training vs. High-Fidelity Simulation | PSNet
      psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
      January 12, 2011 - In the companion article, Dr. … real time and in the environment in which they are needed. … in the clinical arena. … In: Advances in Patient Safety: From Research to Implementation. Volumes 1-4. … U.S. hospitals.

3871. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50756/psn-pdf
      December 18, 2019 - The responsibility to provide education falls on both the prescriber and the dispensing pharmacist. … an effort to decrease alert fatigue by suppressing low priority alerts in the EHR.11  In this case, … could also be observed in high-risk patients on long-term prescription opioids in outpatient settings … and level of involvement in relation to type 2 diabetes mellitus. … Drug—drug interactions that should be non-interruptive  in order to reduce alert fatigue in electronic

3872. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet
      psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
      November 25, 2020 - Patients should lie supine during the exam to avoid vasovagal reactions that could lead to falls and … Hand and wrist tendons may be repaired in the ED or later in the ambulatory setting. … depends on the location and extent of the injury, the clinical setting (e.g., academic versus rural hospital … Extensor and flexor tendon injuries in the hand, wrist, and foot. In: Roberts JR, Hedges JR, eds. … September 29, 2021 WebM&M Cases EMS Perils from Hospital

3873. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
      January 01, 2022 - to a worsening wound from an amputation of the first metatarsal of right great toe at a different hospital … • Upon hospital admission, she was stabilized medically and sent to surgery for a trans-metatarsal … administrations which included inadequate monitoring in a staggering 29% of cases … In: Bradley WG, Daroff RB, Fenichel G, Jankovic J (eds). … In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021.

3874. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet
      psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
      September 01, 2007 - Attarian, written communication, November 2017) In addition, administrative notifications abound in the … Teamwork plays a key role in ambulatory test result management. … Issues and initiatives in the testing process in primary care physician offices. … February 24, 2011 How many hospital pharmacy medication dispensing errors go undetected … U.S. hospitals.

3875. Near Miss with Bedside Medications | PSNet
      psnet.ahrq.gov/web-mm/near-miss-bedside-medications
      February 01, 2006 - Different definitions are in use, which are related to two factors in describing the "near miss-ness" … In fact, capturing every adverse event or near miss can be overwhelming and may be undesirable, as in … In this case, the patient safety committee of the hospital proposed that three actions be taken. … In this case, this might involve an audit to be conducted in 6 months that determines if the specified … In conclusion, there is great power in capturing close calls as a way to improve patient safety.

3876. In Conversation With… Shantanu Agrawal, MD, MPhil | PSNet
      psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
      February 26, 2025 - , and particularly in patient safety. … in its uses? … RW : When NQF started, probably 5% of hospitals had electronic health records, and now 5% do not. … There are more than 5000 hospitals and health systems around the country and many, many more physician … We've done some work in the last couple of years taking steps in this direction.

3877. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome | PSNet
      psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
      April 27, 2022 - After being called at home, the patient returned to the hospital and was admitted with a presumptive … of intravenous antibiotic therapy, the patient developed worsening neurologic symptoms on his third hospital … admissions in 1970-1990 to 2-8 per 10,000 hospital admissions in 2000-2015. 6–8 This increase is multifactorial … An estimated 40,000 to 80,000 preventable hospital deaths attributed to medical errors occur annually … Little Shuteye July 1, 2003 View More See More About The Topic Hospitals

3878. EHR Copy and Paste and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
      January 01, 2018 - Pediatrics University of Wisconsin School of Medicine and Public Health Department of Pediatrics Division of Hospital … March 11, 2020 Using an inpatient portal to engage families in pediatric hospital care … August 1, 2010 Information flow during pediatric trauma care transitions: things falling … Acute Hospital Care Units April 26, 2023 Perspective … Medical Devices June 1, 2011 View More See More About The Topic Hospitals

3879. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
      January 01, 2021 - • After being called at home, the patient returned to the hospital and was admitted with a presumptive … of intravenous antibiotic therapy, the patient developed worsening neurologic symptoms on his third hospital … and cord ischemia. 14 Background (2) • The incidence of SEA has increased from 0.5-2 per 10,000 hospital … admissions in 1970-1990 to 2-8 per 10,000 hospital admissions in 2000-2015. – This increase is multifactorial … The Nature of Adverse Events in Hospitalized Patients.

3880. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head | PSNet
      psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
      March 27, 2024 - The Case A man in his mid-50’s presented to the hospital for a persistent headache after a sledding injury … However, about two weeks later, the patient’s wife insisted that he go back to the hospital for worsening … In this scenario, of course, a false negative CT interpretation would result in a treatment plan that … the community after hospital discharge. … A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital