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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - Over the next 48 hours he was given increasing doses of extended-release morphine (up to a
dose of morphine … He was
found to have new acute renal insufficiency, which likely had contributed to a build-up of opioids
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - essential medications or
enteral nutrition.2
• Larger NGTs ranging from 12 to 18 French (Fr), made up … and confusion.16,17
– The cumulative incidence of delirium ranges from 10% in the acute care setting up
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - are in a hurry, do not understand the importance of antiseptic contact time, and are unlikely to wait up … Take-Home Points
Blood culture contamination is common, constituting up to half of all positive blood
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - handoff communication . 5,6 Stroke Alerts Stroke alerts comprise a mechanism to expedite the work-up … Both the emergency medicine and general neurology teams might have reasonably assumed that the work-up
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - particularly in critical care, that families know their loved one better than staff, and they often pick up … in mental cognition, or they know how the patient responds to certain medications, and they can pick up … I think that some people felt more comfortable speaking up from their kitchen table, on their turf, not … and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the Huddle Up
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - Up to this point, a lot of our models for patient care only focused on one outcome at a time. … Computer algorithms can help pick up tiny signals on a chest x-ray that humans may have difficulty seeing … community resources to address social determinants of health, to better schedule hospital patients for follow-up … Sarah Mossburg: Is there anything that we didn’t discuss today that you’d like to bring up?
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - The Commentary
Acute kidney injury (AKI) is a common condition associated with up to 7% of all hospital
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - August 20, 2018
WebM&M Cases
Medication Mix-Up: From
-
psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - Are specific resources needed, such as mock-up rooms or virtual tools, to integrate safety culture,
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - She had a white blood cell count of 21.4 x 109/L, creatinine of 2.1 mg/dL (up from a baseline of 1.3
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The patient refused a
work-up and was discharged to a skilled nursing facility (SNF).
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - supplementation.(5) Electrolytes,
including but not limited to potassium, have been implicated in up
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - That tends to minimize the vital focus on listening to the patient and following up on her complaints
-
psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - The answer brings up several issues in patient safety for prehospital, ED, and hospital care:
Issue
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - However, the patient's family was unable to pick up the prescription for 3 days.
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - advantages of straddling the research and operational line, which is if you can do this work well, it opens up … safety issues were built nicely on our previous sociotechnical approaches to understanding and improving follow-up … having the confidence that if you care, it's an important issue and the world will eventually catch up
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - studies have shown that direct CEO-level accountability is associated with gains in safety. 7 In a follow-up … they just seem a little off today, and I communicate that, that seeming a bit off might get picked up … are just going to help individuals become personally resilience and then our organization will scale up
-
psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - they just seem a little off today, and I communicate that, that seeming a bit off might get picked up … are just going to help individuals become personally resilience and then our organization will scale up … studies have shown that direct CEO-level accountability is associated with gains in safety. 7 In a follow-up
-
psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - Duration varies among campuses, up to 9 months;
Course is 8 days, plus time for a QI project;
Content
-
psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - In such a setting, each doctor has a
responsibility to follow through on any identified factors that … Do you usually get chest pain or breathlessness when you climb up two flights of
stairs at normal speed