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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.242_slideshow.ppt
June 01, 2011 - I was a bit shaken up and because I was not sure of the cause, I took her to see her pediatrician.
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - in the ambulatory setting is ubiquitous, many practices still lack reliable systems for following up
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
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/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - Case reviews are conducted by an interdisciplinary team and include follow-up to ensure a treatment plan … Prescribing protocols follow the A/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Case reviews are conducted by an interdisciplinary team and include follow-up to ensure a treatment plan … Prescribing protocols follow the A/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - the collective dose to the population and fluoroscopy and conventional radiograph examinations making up … When people scan a plastic dummy, you set a protocol that you follow very closely. … The doses crept up and no one really noticed it. … So as the doses went up, we were thinking about this problem less, and when attention came to this issue … We're developing strategies that we hope can be scaled up rapidly to allow us all to get on the same
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psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
June 29, 2020 - ICU bed expansion, members of the workforce that are working remotely or are furloughed, or keeping up … taken to allow for less exposure within a traditional dispensing pharmacy, such as encouraging drive-up … To enable competency development, we opened up a critical care certification course to members, non-members … of members is a Business Recovery Toolkit , aimed at informing next steps as the nation opens back up … We’re really pleased that we are able to open up all of these resources, not just for our members but
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - clinician not ensuring the environment was safe before leaving the room by placing the side rail back up … of siderail(s) to prevent falls is controversial, especially if they are used as a restraint (all 4 up … We also do not know if having the rail up for the first patient would have prevented a fall. … for patients who are not able to call for assistance would include ensuring that upper side rails are up … cognitive impairment) that may impact the safety or quality of healthcare; flags can be configured to pop up
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - clinician not ensuring the environment was safe
before leaving the room by placing the side rail back up … of siderail(s) to prevent falls is controversial, especially if they are used as a restraint (all
4 up … We also do
not know if having the rail up for the first patient would have prevented a fall. … patients who are not able to call for assistance would include ensuring that upper
side rails are up … cognitive impairment) that may impact the safety or quality of
healthcare; flags can be configured to pop up
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
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…
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - Crisis
March 15, 2023
WebM&M Cases
Speaking Up
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Still, patients in hospitals fall up to 1 million times per year. 7 An estimated 30% of these falls
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Also, the hierarchal nature of medical practice frequently inhibits team members from speaking up.
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psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - TSOACs) have become available for the treatment and prevention of thromboembolism and currently make up
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - At the SNF, a follow-up complete blood count showed a hemoglobin level of 7.1 g/dL (normal 12–16 g/dL
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - steps toward successfully processing errors, accepting responsibility is
crucial, as is the logical follow-up
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psnet.ahrq.gov/node/60172/psn-pdf
March 01, 2021 - One
study, for example, found that clinical notes meant for one patient ended up in a different patient's
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - instead of solely focusing on active failures (in this case, the anesthesiologist's unfortunate drawing up
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 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