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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up … Imaging tests confirmed metastatic
prostate cancer and also uncovered the missed follow-up of the elevated … It's not
always clear what follow-up instructions a patient was given by an outgoing clinician, or whether … a patient
failed to initiate follow-up. … Academic year-end outpatient transfers: identifying and improving
follow-up of high risk psychiatry
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - acts
as the health care entry point for uninsured patients who lack a primary care provider to offer follow-up … telephone translation, and interconnected electronic medical records provide some
support, the lack of follow-up … abnormal vital signs, unrecognized decompensation of
chronic disease, and impaired communication or follow-up … use of decision aids that help structure problem analysis and resolution;5,15 and (iv) provision of
follow-up … provide valuable patient-specific data as well as reference materials, and
provide assistance with follow-up
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - She was instructed to follow up with an orthopedist as soon as possible. … Due to transportation difficulties, the patient was not seen in follow up.
Case: Right? … The family requested an orthopedic consultation to expedite work-up. … Sentinel Event Alert: A follow-up review of wrong site surgery. … responsible for admitting the patient or to the consulting orthopedic surgeon
Second Error: Follow-up
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psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
February 01, 2004 - He was discharged home with an indwelling urinary catheter and a follow-up appointment with the same … At that follow-up appointment, he was told he was "ready for surgery"—despite his fears of potentially … More than 3 years of follow-up, 3/280 men developed renal decompensation in the surgery group, versus … After 4.5 years of follow-up, not a single man in any study arm developed renal failure related to BPH … Over the ensuing 10 weeks, the patient, distrustful of the clinician he encountered, canceled his follow-up
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psnet.ahrq.gov/node/41748/psn-pdf
April 05, 2013 - of strategies to prevent readmissions
such as postdischarge telephone calls and early primary care follow-up … complementary-telephone-strategies-improve-postdischarge-communication
https://psnet.ahrq.gov/issue/effect-hospital-follow-appointment-clinical-event-outcomes-and-mortality
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psnet.ahrq.gov/node/41175/psn-pdf
December 31, 2014 - A past AHRQ
WebM&M commentary discussed an adverse outcome that resulted from poor test follow-up after … psnet.ahrq.gov/issue/adequacy-hospital-discharge-summaries-documenting-tests-pending-results-and-outpatient-follow
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psnet.ahrq.gov/issue/errors-upstream-and-downstream-universal-protocol-associated-wrong-surgery-events-veterans
November 21, 2012 - A follow-up study from US Veterans Health Administration medical centers. … A follow-up study from US Veterans Health Administration medical centers.
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psnet.ahrq.gov/node/39540/psn-pdf
February 17, 2011 - delays that may result from inadequate confirmation of
contact mechanisms and protocols for patient follow-up
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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - The question is: which causes do you
end up finally addressing or trying to mitigate. … You notice we don't include anywhere in the criteria whether you broke a rule or didn't follow a rule … Just because you didn't follow the rules
doesn't mean you did the something wrong from a patient care … You have to build in a
follow-up process and an action plan, and you need to have the right people around … And they don't
follow up. Really, part of this is culture.
RW: Yeah, and leadership.
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psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem
March 13, 2013 - Related Resources From the Same Author(s)
Nursing crew resource management: a follow-up … A follow-up study from US Veterans Health Administration medical centers.
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psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
July 16, 2015 - A follow-up study from US Veterans Health Administration medical centers. … January 4, 2012
Incorrect surgical procedures within and outside of the operating room: a follow-up
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psnet.ahrq.gov/node/36910/psn-pdf
August 05, 2008 - reports on a Pennsylvania hospital system that offers a flat fee for bypass surgery and a
guarantee for follow-up
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psnet.ahrq.gov/node/38366/psn-pdf
January 28, 2009 - utility of incident reports is limited by lack of standardized mechanisms for classifying and following up … Over a 4-year follow-up period, the frequency of most types of incidents declined significantly.
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psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive
June 04, 2014 - June 5, 2018
Loud wake-up call: unlabeled containers lead to patient’s death. … April 29, 2018
When I follow up, I don't give up. … February 25, 2009
WebM&M Cases
Citrate Mix-Up
May
-
psnet.ahrq.gov/node/42766/psn-pdf
November 27, 2013 - biggest-mistake-doctors-make
This newspaper article describes efforts to prevent diagnostic errors, including improving follow-up
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psnet.ahrq.gov/issue/errors-cancer-diagnosis-current-understanding-and-future-directions
November 18, 2009 - July 10, 2008
Improving follow-up of abnormal cancer screens using electronic health … April 14, 2011
Timely follow-up of abnormal diagnostic imaging test results in an outpatient
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psnet.ahrq.gov/issue/using-fda-reports-inform-classification-health-information-technology-safety-problems
November 03, 2015 - March 4, 2015
Last orders: follow-up of tests ordered on the day of hospital discharge … July 17, 2019
The impact of health information technology on the management and follow-up
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psnet.ahrq.gov/issue/building-ambulatory-safety-program-academic-health-system
April 22, 2016 - Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up … March 13, 2019
Understanding test results follow-up in the ambulatory setting: analysis
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psnet.ahrq.gov/issue/getting-it-right-patient-safety-specimen-collection-process-improvement-operating-room
July 16, 2013 - , 2024
The delivery of safe and effective test result communication, management and follow-up … November 1, 2023
Interventions to improve follow-up of laboratory test results pending
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psnet.ahrq.gov/node/842417/psn-pdf
January 11, 2023 - Scaling-up a pharmacist-led information technology
intervention (PINCER) to reduce hazardous prescribing … Scaling-up a pharmacist-led information technology intervention
(PINCER) to reduce hazardous prescribing … found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-
month and 12-month follow-ups