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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - The primary care physician should follow up with a phone call 24 hours after admission to review the
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Active factors
are usually apparent and expected but when latent factor holes “line up”, an error in … National reports of events are collated and made public with follow-up to device manufacturers
on safety … Better policies contain
guideline-based and up-to-date recommendations and explain the rationale for
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - It crept up on us and by the time people woke up to the danger, we were already pretty far in the boiling … And I said, "No, up." "Were there 200,000?" … These monitors are computer devices, so there could be prompts that would come up and help the user—the … For example, a prompt could come up indicating that this patient's heart rate has averaged 135 for the … If you're a novice, then 1, and up to 3 if you're an expert.
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psnet.ahrq.gov/web-mm/suicide-risk-hospital
November 01, 2011 - Cases
Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
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psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - conclusions, but of the small number of atrial fibrillation alerts produced, only 34% were
confirmed by follow-up
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - must be prepared to direct participants to
appropriate resources if they are not able to interpret or follow … up on the findings because such findings
may have both physical and emotional ramifications, as they
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
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
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
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
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psnet.ahrq.gov/web-mm/liposuction-gone-awry
July 01, 2003 - Liposuction Gone Awry
Citation Text:
Yates JA. Liposuction Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - When these things happen to our members, they end up in the hospital. … The plan may also learn a provider issued a prescription that was not picked up at the pharmacy by the … Whether prescriptions got picked up, the number of refills actually filled over time, or whether another … We follow claims data and complications as they're coded, as well as unplanned care and admissions into
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - When these things happen to our members, they end up in the hospital. … The plan may also learn a provider issued a prescription that was not picked up at the pharmacy by the … Whether prescriptions got picked up, the number of refills actually filled over time, or whether another … We follow claims data and complications as they're coded, as well as unplanned care and admissions into
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - But we have more than 12,000
employees in our institution—so, how would you like to follow all employees … We performed a literature review (in press) of 48 studies published up to the end of last
year. … To back this up, there are studies where
system change has been implemented as the only parameter to
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - patients are often relocated within the hospital and home medication must be tracked to appropriately follow … Related Resources
WebM&M Cases
Medication Mix-Up
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - TSOACs) have become available for treatment and prevention of thromboembolism
TSOACs currently make up
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - It is up to the health care administrators, providers, and
surgeons to ensure that the protocol is implemented
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - preparing medications for
patients ranging in weights from 400 g to 120 kg, resulting in the potential of up
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Up
to 40 people per session have been effectively trained in one model (2), which comports with our
-
psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - reported as
unremarkable, and basic laboratory tests and an abdominal computed tomography (CT) study came up
-
psnet.ahrq.gov/node/49502/psn-pdf
February 01, 2006 - Finally, there must be adequate back-up systems for managing computer slowdowns and
power failures.
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psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - Anyone who has ever drawn up a physician or nursing schedule recognizes the stark truth: hours worked