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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - and practice of IR
includes evaluation and management, patient consultation, treatment planning, and follow-up
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - quality information about my fall risk or I can work with my
healthcare team to ensure that my visitors follow … LH: Exactly, and to leverage that as a strategy opens up so much potential in creating healthy
communities … The ROI question, how soon does that come up? Are you
going to just start doing this?
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - optimal one is unclear, and I'm sure that people
with more expertise in that area than me will come up … you were a patient and you saw those videos, you would be quite scared that you were going to end
up … patients, and my hope is that over the next several years that
the other professional organizations follow
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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - the nurse’s suggestion that the tip was in the chest cavity, and thus at the end of the case did not follow … differently); knowledge that did not make it into the team consciousness (due to fear of speaking up
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Hemolysis Holdup
May 1, 2017
Diagnostic error in the emergency department: follow … up of patients with minor trauma in the outpatient clinic.
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psnet.ahrq.gov/node/49419/psn-pdf
October 01, 2003 - When
the patient returned for routine follow-up, the surgeon performed a vulvar colposcopy and biopsied
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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - are added at appropriate places in the electronic medical record to allow for quick reference look up … WebM&M Cases
Critical Echocardiogram Result Lost to Follow-up
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - , and others) often work in different areas of a hospital or clinic, deliver asynchronous care, and follow … ordering the wrong chemotherapy regimen.( 16 ) Fortunately, an alert patient had the courage to speak up … June 14, 2019
Electronic prescribing vulnerabilities: height and weight mix-up leads
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - The patient obtained the necessary cardiac follow-up and her surgery was rescheduled. … February 1, 2010
WebM&M Cases
Coming Up Short
-
psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - The call has occupied your attention and because you are distracted, you follow an initially similar, … You can just put your hand up or shake your head, "I'm on the phone," that sort of thing. … For example, computer designers know that it is a really bad thing to have an alert window pop up and … So it brings up this issue of smartphones and the ubiquity of technology. … It's up to us to configure them in the right way.
-
psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
May 28, 2020 - Unfortunately, people can miss things, and they are certainly not going to pick up on all associated … NEST will allow us to build up an active surveillance capability in combination with our existing passive … asked to evaluate new science and new technologies, we are always trying ensure that we are keeping up … Or is it going to be up to the device manufacturers to put in place safeguards?
-
psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - medications, she was asked why she was taking topiramate; the daughter
recalled her mother picking up … The medication was then picked up by the patient from her usual pharmacy. … psnet.ahrq.gov//#T1
https://psnet.ahrq.gov//#9
https://psnet.ahrq.gov//#10
body language cues to pick up … nurse to that received by the pharmacy
Ask questions if something doesn’t seem right
When picking up
-
psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - What we were trying to figure out was, what were the key considerations while setting up COVID-
19 testing … community and local site-level factors that will
determine where COVID-19 testing sites should be set up … In the traditional design of a hospital, you set
it up in a hierarchy of space from sterile to non-sterile … For example, is the patient getting up to
go to the bathroom without calling a nurse and putting themselves
-
psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - Unfortunately, people can miss things, and they are certainly not going to pick up on all associated … NEST will allow us to build up an active surveillance capability in combination with our existing passive … asked to evaluate new science and new technologies, we are always trying ensure that we are keeping up … Or is it going to be up to the device manufacturers to put in place safeguards?
-
psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - decided that I wanted to turn EMS [emergency medical services] into my full-time career, and I ended up … NEMSIS has done a really good job at partnering with all of the vendors to come up with a suggested list … So we feel like it's really important to set up the baseline, because it's possible to improve that. … So, I think that this progression is probably at a natural point, but it's picking up quickly, and I'm … Study
Catching those who fall through the cracks: integrating a follow-up
-
psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The patient refused a work-up and was discharged to a skilled nursing facility (SNF). … Quality
April 26, 2023
WebM&M Cases
Coming up
-
psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - increasingly uncomfortable with the conversation, the patient in the neighboring bed finally spoke up … Patients with the same (or similar) names are often found within most health care systems, with up to
-
psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - as seizures or coma, the panel recommended use of a 10-minute infusion of 100 ml 3% saline, repeated up … Related Resources
WebM&M Cases
Medication Mix-Up
-
psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - It was started at a low dose but then titrated up to 20 μg/hr to address the patient's continued hypotension … Canadian Association of Emergency Physicians endorses the use of peripheral vasopressor administration for up
-
psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - between the day crew – that presumably consulted
on the patient – and the on-call team that ended up … Once the plan is developed for such a patient, it is important to follow it as prescribed.