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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - The intravenous fluid was opened up as a bolus. The uterus was boggy on examination.
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - A follow-up study from US Veterans Health Administration medical centers.
-
psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - We have also developed benchmarks for nurses to follow and to measure competency. … The catheter may curl or kink in the urethra, butt up against one of the urethral curves, bend at the … All personnel must follow evidence-based guidelines on urinary catheterizations and receive periodic
-
psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - He woke up and was able to be extubated safely later that day.
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Tomography (CT) suite includes many sources of interruptions that may make it difficult for staff to follow … Event
January 29, 2020
WebM&M Cases
Speaking Up
-
www.ahrq.gov/sites/default/files/2024-04/naughton-report.pdf
January 01, 2024 - The index represents a case-
finding tool that should be followed up with a bedside assessment that
-
psnet.ahrq.gov/node/857260/psn-pdf
November 30, 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
-
psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Although it is true that free air under the diaphragm is reported in more than half of follow-up radiographs
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/alcohol-misuse-drug-therapy_clinician.pdf
February 01, 2016 - Important social, occupational, or recreational activities are given up or
curtailed because of alcohol
-
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
-
hcup-us.ahrq.gov/reports/statbriefs/sb3.pdf
April 01, 2006 - Payer
Up to two payers can be coded for a hospital stay in HCUP data.
-
effectivehealthcare.ahrq.gov/sites/default/files/15_crosscutting_potential_high_impact_june_2012.pdf
January 01, 2012 - The system
is intended to identify interventions that purport to address an unmet need and are up to … 7 years out
on the horizon and then to follow them for up to 2 years after initial entry into the … ,]
better disease state management could occur.”
25
However, two other experts noted that it is up … through 01 July 2007 show a
monthly average of 950 ED patients surveyed and 80% of these accepting follow-up … by improving patient safety (structural changes), focusing care delivery
(protocols), and improve follow-up
-
digital.ahrq.gov/sites/default/files/docs/page/CDS_challenges_and_barriers.pdf
July 30, 2007 - of care provided.7-10 CDS alerts, reminders, and standardized order sets can also help
clinicians follow … for $2.5 million for a 2-year period, with an option for AHRQ to continue funding the
projects for up … ranged from “clinicians should consider the recommendations” to “clinicians should be required
to follow … They do so because they feel that the hardware is not up to date and is slow. … Clinicians may lack motivation to use CDS applications because
they believe that they already know and follow
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening-june-2018
June 26, 2018 - forearm and heel) to identify persons with low bone mass; however, most treatment guidelines recommend follow-up … thromboembolism with estrogen therapy, and an increased risk of urinary incontinence during 1 year of follow-up … compared with women taking placebo, and an increased risk of urinary incontinence during 1 year of follow-up
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/action-plan-trip-fac-guide.html
February 01, 2017 - Slide 32: Test of Change Examples
Say:
The Centers for Disease Control and Prevention-funded Wake Up
-
www.ahrq.gov/cahps/quality-improvement/improvement-guide/5-determining-focus/index.html
February 01, 2020 - for urgent care as soon as needed
64%
64%
81%
74%
66%
58%
Got appointment for check-up
-
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
-
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.
-
hcup-us.ahrq.gov/db/nation/nis/APS-DRGsDefManualV25Public.pdf
June 01, 2009 - When this look-up process is complete, proceed to Step 8.
8. … When this look-up process is complete, proceed to Step 9.
9. … Do not follow any
additional instructions. … Do not follow any
additional instructions. … For this look-up process, use the MS-DRG originally assigned to the
medical record.
-
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