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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - intracellular cytosol that is secreted and flows in the circulation system of lactifer plants, which make up … proportions in specific groups 5-8 , 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 to … 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-nicholas-g-castle-mha-phd
August 01, 2012 - the survey that reflect staffing issues and transition between unit issues—similar to what we picked up … So again we're coming up with the conclusion that, at least in comparison to hospitals, nursing homes … RW : What keeps you up at night as you think about the aging population in terms of nursing home care … It is not a matter of just housing residents in a room and watching TV all day or lining them up in corridors
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - While this provided excellent security, it was not usable once we scaled up our data collection. … 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
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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - the survey that reflect staffing issues and transition between unit issues—similar to what we picked up … So again we're coming up with the conclusion that, at least in comparison to hospitals, nursing homes … RW : What keeps you up at night as you think about the aging population in terms of nursing home care … It is not a matter of just housing residents in a room and watching TV all day or lining them up in corridors
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psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
March 01, 2017 - people behave, the norms that guide them, the values that seem to inform their practice, how that shows up … in organizational routines, how it shows up in how people behave toward each other. … People often say what we, as social scientists, do is hold up a mirror. … You could say that it's up to systems to detect and deal with these. … I completely agree—systems and culture both end up being dustbin terms that don't take us very far.
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psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
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/unintended-consequences-cpoe
September 01, 2004 - She presented with sepsis and acute kidney injury with a creatinine of 2.0 mg/dL (up from a baseline … introduction of new technologies in other spheres—some paths to failure are closed off, but new ones open up … User interfaces should follow well-established ergonomic principles to minimize error traps.
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - 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/837963/psn-pdf
August 31, 2022 - ischemia, and risk factors for each
cause/mechanism
Explain how the differential diagnosis and work-up … None of these
physicians followed up on the possibility of mesenteric ischemia, reportedly because they
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - may also precipitate post-obstructive pulmonary edema,13 which is diagnosed when the
patient coughs up … hypoxia and bradycardia, it may be necessary to administer a
larger dose of muscle relaxant to speed up
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - medication).(15)
To enter this order in the computer, a clinician might consider using a "ramp up … Medication
April 1, 2010
WebM&M Cases
Citrate Mix-Up
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - vitro hemolysis is common, contributing to approximately 40% of all laboratory errors and affecting up … medications simultaneously, and should consider monitoring with telemetry and pulse oximetry and repeat follow-up
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - staff—assuming that a culture of psychological safety exists so that
nurses are empowered to speak up
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - Sign up today to get weekly and monthly updates via emails!
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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - medically complex homebound or
home-limited patients, those who typically have difficulty attaining follow-up … Starting up a hospital at home program: facilitators and
barriers to implementation.
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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - RW : Yeah, I'm glad you brought that up in terms of the days of the giants. … You brought up training people as to what represents a useful note in this era. … Let's say it's a heart failure patient, and she'll say, "BUN and creatinine are up a little bit. … I think that the increase in nurse practitioners and physicians' assistants will free up physicians to … time will be spent at the bedside or freed-up time will be spent with more technology.
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - 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/node/74252/psn-pdf
January 12, 2022 - before COVID-19—has been very focused on patient safety
and avoiding patient harm, but they’ve stepped up … Documentation systems were
challenged throughout by setting up new departments or changing area functions … They set up incredible systems, very quickly, and provided
excellent patient care.
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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - understand some information in the record and it would cause stress or harm, which actually did not
end up … them, there's a light at the end of the
tunnel, eventually all of this improvement work will clean up … RW: When this job opened up, you were in a very prominent role in patient safety at a world-renowned
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - acute care hospitals, pressure ulcer incidence after hip
fracture ranges from 36.1% (United States) to up … for pressure ulcers occurring in
hospitalized patients are the sacrum, coccyx, buttocks, and heels (up … surgery have revealed that skin changes
associated with deeper tissue ischemia may not be apparent for up