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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - I picked up the chart that
was next to this patient. The chart was correct for my next patient. … anesthetist checked the patient's wristband
and alerted the nurse to her error—the chart the RN had picked up … However, if all that
results is a single individual vowing never to slip up again, the system will remain
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - Covering these duties freed up the onsite team to see more patients and focus on bedside clinical management … 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/node/49567/psn-pdf
September 01, 2008 - A more extensive work-up
pursued to evaluate for atypical and fungal pneumonia revealed no culprit organism … significantly less joint
damage progression after 2 years than those on either sequential monotherapy or step-up … empiric steroids, 80–100 mg
prednisolone/day, intravenously, are appropriate therapy while the work-up
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - I had a formative experience working in a rural community, and it left an imprint on me that ended up … We need education to rise up and become a part of that environment. … How does the funding model and organizational changes in health care delivery systems sync up with the … faculty, using the Institute for Healthcare Improvement Open School and other resources to get them up … Then, 2 years later we opened up this consortium with smaller awards to another 21 schools.
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - I had a formative experience working in a rural community, and it left an imprint on me that ended up … We need education to rise up and become a part of that environment. … How does the funding model and organizational changes in health care delivery systems sync up with the … faculty, using the Institute for Healthcare Improvement Open School and other resources to get them up … Then, 2 years later we opened up this consortium with smaller awards to another 21 schools.
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - intracellular cytosol that is secreted and flows in the circulation system of lactifer plants, which
make up … proportions in specific groups5-8, 21-34 during the early identification of this
disease, including up … A simple comparative example is that it is virtually impossible to hook up the
oxygen source tubing … When latex allergy is documented in the medical record, an alert could be programmed to pop up for
the
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - We're told that a lot of the appeal for the organizations that have signed up to become PSOs comes from … same kinds of reports that are available for the local institution provide the foundation for rolling up … to the best of my knowledge, address the issues of privilege and confidentiality in a way that sets up … While this provided excellent security, it was not usable once we scaled up our data collection.
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - configuration of the ADC itself to the retrospective review of overrides. 7,8 ADC Configuration ADCs can be set up … Cases
Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
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psnet.ahrq.gov/node/33800/psn-pdf
January 01, 2015 - commercial CPOE systems are not yet optimized to promote
medication safety and should serve as a wake-up
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - in the ambulatory setting is ubiquitous, many practices still lack reliable systems
for following up
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - , Safety-II, where aspects of
care that went well are identified and used to standardize and scale up
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psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - We will continue to
encourage colleagues to speak up and share their stories—with our experience or
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - Every once in a while, it gets caught up in that scar tissue, and women bleed to death. … show that the nurse that gets randomly assigned to you can influence your odds of getting a C-section up … One thing that has driven up the C-section rate is when we introduce physiologic monitoring of labor. … technology can tell you how big a pelvis is, how big an infant's head is, or how the two are lined up … RW: How do you come up with a system where you can have that meaningful level of engagement?
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - The intravenous fluid was opened up as a bolus. The uterus was boggy on examination.
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - A follow-up study from US Veterans Health Administration medical centers.
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - We have also developed benchmarks for nurses to follow and to measure competency. … The catheter may curl or kink in the urethra, butt up against one of the urethral curves, bend at the … All personnel must follow evidence-based guidelines on urinary catheterizations and receive periodic
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - He woke up and was able to be extubated safely later that day.
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Tomography (CT) suite includes many sources of interruptions that may make it difficult for staff to follow … Event
January 29, 2020
WebM&M Cases
Speaking Up
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psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - dapagliflozin, and empagliflozin) be stopped three days before scheduled surgery and
ertugliflozin stopped up … Evidence-based Guidelines:
Develop and follow evidence-based guidelines for medication management prior
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Although it is true that free air under the diaphragm is reported in more than half of follow-up radiographs