-
psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - Finally, an algorithm to detect patients in need of follow-up after test results was developed and implemented … for fall detection using multiple cameras and convolutional neural networks: a case study using the UP-Fall
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - The following precautions were taken: Side rails up; Bed in lowest possible position; Call light immediately … WebM&M Cases
Critical Echocardiogram Result Lost to Follow-up
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - This campaign encourages women, families, and health providers to identify and speak up with concerns … This campaign encourages women, families, and health providers to identify and speak up with concerns
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Third, an internal resource pool of RNs available and incentivized to provide the ability to flex up … Rather than using
the bedpan, the patient insisted on getting up and going to the bathroom. … flexibility of a resource pool and keen daily budget
management enable the CNO and other nurse leaders to follow
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - While this provided excellent security, it was not usable once we scaled up our data collection.
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Anyone who has ever drawn up a physician or nursing schedule recognizes
the stark truth: hours worked
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psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - L), lactic acidosis (9.9 mmol/L),
and new acute kidney injury (creatinine 1.8 mg/dL, up from a baseline
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Cases
Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - Covering these duties freed up the onsite team to see more patients and focus on bedside
clinical management … healthcare workers
caring for patients with COVID-19.4
Results
According to the innovation team, dividing up … virtual
hospitalists logged a daily median of 105 minutes on the phone with families, with some days of up
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - a colleague related the story of a patient whose coronary bypass operation was canceled, but showed up … Many things had to go wrong for all these mistakes (ie, the "holes in the Swiss cheese") to line up.( … January 29, 2014
When surgery goes wrong: weighing up the risks.
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - In this case, it seems that both the high-flow oxygen mask and the self-inflating bag were hooked up … "(3)
Much of the gas delivery system is designed to avoid hooking up the wrong gas hose to a compressed … end of an anesthetic, the anesthesiologist might reach back to turn off the
nitrous oxide and turn up
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - He felt that his resident didn't speak up to adequately address the allergy concern,
in part because … determinant of the success of time outs; without it, the ability
of people lower on the totem pole to speak up … pervasiveness of traditional cultural barriers that prevent some
members of the team from speaking up
-
psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - Since the IOM report, we have been following up to see whether any evidence shows that the culture of … And these differences line up very closely to the variation across hospitals
in mortality, infection … need for more nurses,
and that is one of the reasons why hospitals perceive that they cannot catch up
-
psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - technology or flawed systems design;
lack of evidence for effectiveness of solutions; insufficient follow-up
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - An office must have competent personnel, up-to-date equipment and monitors, preventative maintenance
-
psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - For example, during insertion of the insufflation needle, it is important for the assistant to “tent up
-
psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - The flow of fluid through the humeral head is superior—up to five times higher—to that in the tibial
-
psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - prescription.12 Other PSLLs have used HFE to analyze failure to rescue and address radiology
ordering and follow-up
-
psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - January 19, 2014
A long-term follow-up evaluation of electronic health record prescribing
-
psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Cases
Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up