-
psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - accommodate increased staffing requirements, hospitals use a combination of scheduling strategies to “flex” up … the course of the RCA, determination of how a nurse without proper orientation or supervision ended up
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - been called into
question, as many institutions lack a formal mechanism for implementing and following up … been called into
question, as many institutions lack a formal mechanism for implementing and following up
-
psnet.ahrq.gov/node/33621/psn-pdf
November 01, 2005 - multi-hospital Australian study found no benefit, but
the implementation was somewhat flawed and the follow-up
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - This mix of
top-down implementation and bottom-up customization has been instrumental in ensuring that … In the face of these attributes, some private sector organizations will be able
to follow, whereas others
-
psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Centers for
Disease Control and Prevention (CDC) created a series of universal precautions for HCWs to follow … smallpox virus, variola
major, is highly contagious, readily transmitted person-to-person, and fatal in up
-
psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - This
pause also encourages all individuals present to speak up about potential patient safety threats … Explicit, step-by-step instructions presented in an
easy-to-follow manner provide the best chance for
-
psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Neither the patient nor the parents had received education on how to draw up and administer insulin using … Insulin vials require the patient (or caregiver) to draw up insulin via a syringe. … for a sicker patient, they might have directed her family to drive to the outside pharmacy to pick up
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - 150 x 109/L or by ≥ 50% below baseline
Timing: within 5-10 days of heparin exposure
Thrombosis: up … IV bolus followed by
2.5 mg/kg/hr infusion for 4 hours; may continue infusion at
0.2 mg/kg/hr for up … thrombosis—minimum of 3-6 months
HIT without thrombosis—risk of thrombosis persists for at least 30 days, with up
-
psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
January 01, 2022 - • This process results in an ongoing low level of infection, affecting up to 30%
of the population … type 1 (HTLV-1), or severe malnutrition), Strongyloides
replication can increase, leading to a build-up … which should
have raised suspicion of a potential parasitic infection.
– Recognizing and following up
-
psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - I don't think we should be taking up the scarce
resources of health care organizations by focusing them … But they wonder whether these organizations can clean it up so that it is coming
in a single voice with … Do you feel like the science and the data sources are up to the task?
-
psnet.ahrq.gov/node/33624/psn-pdf
December 01, 2005 - Well,
they were in the middle of a tort crisis in California, and coming up with numbers that suggested … So we were just as interested in following up on
legal claims as we were in reviewing the medical records … search for a different approach that
accurately identifies when these incidents are occurring and sets up
-
psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - In Florida, $1 million coverage will cost in liability premiums up to $250,000 per year for neurosurgeons … multiple factors contribute to increased premium rates, losses on medical malpractice claims—which make up … malpractice.( 4 ) Unique 2004 legislation created the Florida Patient Safety Corporation, which set up
-
psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - importantly, writing vague orders such as "medications as at home" can be confusing and leave too many things up … Resources From the Same Author(s)
WebM&M Cases
Citrate Mix-Up
-
psnet.ahrq.gov/node/49457/psn-pdf
September 01, 2004 - In the United
Kingdom, where the entire population is required to have a personal physician, up to 99%
-
psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - A few hours later, the patient stood up from bed to use the urinal, began coughing, turned cyanotic,
-
psnet.ahrq.gov/node/49668/psn-pdf
October 01, 2012 - prior and was given a prescription for oral antibiotics and other medications, which he never picked up
-
psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - , frequency of administration, and type of the toxin used.( 7 ) In typical clinical settings, doses up
-
psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - An office must have competent personnel, up-to-date equipment and monitors, preventative
maintenance
-
psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - But it's also because there were bad errors that were embarrassing and ended up in the media. … That tension comes up a lot, where hospitals will often say leave us alone because if it's too public … SK: When the media reports about some hospital that screwed up, it's really, "here's the story." … came to us a year or two after Josie died, and it was a story about a hospital that really screwed up … They need to trust the doctors and the nurses and they cannot put up this wall of animosity in front
-
psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - January 19, 2014
A long-term follow-up evaluation of electronic health record prescribing