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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis
323
Improving the Safety of Heparin
Administration by Implementing a
Human Factors Process Analysis
Kathleen A. Harder, John R. Bloomfield,
Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush,
Jamie S. Sinclair,…
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ce.effectivehealthcare.ahrq.gov/teamstepps/events/webinars/jan-2017.html
January 01, 2017 - Event Manager (TL) to run the code
CPR Team
Access (hemorrhage, need large bore access)
Airway
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-fullreport.pdf
April 01, 2019 - o Skull fracture.
5
o Intracranial hemorrhage.
• Neurological surgery. … malpractice-sensitive physician is faced with a potentially
worrisome condition (e.g., intracranial hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-196-fullreport.pdf
January 01, 2020 - situations, for example, when imaging must be obtained emergently or there is
concern for intracranial hemorrhage … patients who require timely
9
imaging in the acute clinical setting or when intracranial hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-fullreport.pdf
November 01, 2019 - situations, for example when imaging must be obtained emergently or
there is concern for intracranial hemorrhage … CT is usually the imaging study of choice for identification of intracranial hemorrhage,
despite the
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
January 01, 2003 - 1.37***
GU complications 1,956 3.5 0.86***
Infection/inflammation 4,203 7.5 2.01***
Hematoma, hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
July 01, 2023 - Response
Every Case
Reporting
Every Unit
N/A N/A Use DESCR:
• To unit‐standard, stage‐based, OB
hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
July 01, 2023 - Patient Response
Every Case Reporting
Every Unit
N/A N/A Use DESCR:
To unit-standard, stage-based, OB hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
May 01, 2016 - clinician input, the grantee identified four obstetric clinical events—shoulder dystocia,
postpartum hemorrhage … section, White women rather than Black women,
and drug overdose played a greater role in deaths than hemorrhage
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
January 01, 2003 - puncture or laceration during the
procedure, foreign body left in during the procedure, post-operative hemorrhage … Hypothyroidism 0.012 0.013
Renal failure 0.020 0.057
Liver disease 0.003 0.003
Peptic ulcer disease x bleeding
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel_facnotes.docx
December 01, 2017 - Patient outcomes, including patient care experience,
· Infection rates and sepsis rates,
· Post-op hemorrhage
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ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/on-boarding/overview-fac-notes.html
December 01, 2017 - Post-op hemorrhage.
Respiratory failure.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-133-fullreport.pdf
January 01, 2019 - /sepsis (14.0 percent), non-cardiovascular diseases (11.9
percent), cardiomyopathy (11.8 percent), hemorrhage … Postpartum hemorrhage: The role of the maternal–fetal medicine
specialist in enhancing quality and patient
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ce.effectivehealthcare.ahrq.gov/patient-safety/resources/learning-lab/index.html
April 01, 2024 - Results included a reduced mortality rate of patients with atraumatic intracerebral hemorrhage (ICH) … or subarachnoid hemorrhage (SAH) from 29 percent before intervention to 11 percent postintervention.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - • Postoperative hemorrhage or hematoma with surgical drainage or evacuation per 1,000
surgical hospital … for cardiac and noncardiac surgery, postoperative pneumonia, iatrogenic pneumothorax, postoperative
hemorrhage … for cardiac and noncardiac surgery, postoperative pneumonia, iatrogenic pneumothorax, postoperative
hemorrhage … The three initial targets of the HHS National Action Plan for Adverse Drug Event Prevention are:
Bleeding … Anticoagulants, such as warfarin,
reduce this risk but pose an increased risk of bleeding.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa4.pdf
January 01, 2018 - professional about eating fewer
high-fat or high-cholesterol foods
9.9 2.23 MEPS 2016
Postoperative hemorrhage … during hospitalization, adults ages 18-89 or obstetric admissions
2.7 1.31 HCUP 2016
Postoperative hemorrhage … Adults age 65 and over who ever received pneumococcal vaccination 1.4 0.25 NHIS 2017
Postoperative hemorrhage
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - clinician input, the grantee identified four obstetric clinical events—shoulder dystocia,
postpartum hemorrhage … section, White women rather than Black women,
and drug overdose played a greater role in deaths than hemorrhage
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_tools.docx
January 01, 2012 - Postfall Assessment, Clinical Review
Note: There is increased risk of intracranial hemorrhage in patients … check all that apply
Injury
Yes
No
Site of Injury
Abrasion/bruise/laceration/hematoma
Bleeding
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ce.effectivehealthcare.ahrq.gov/teamstepps/lep/traintrainers/lepigtrainer.html
October 01, 2020 - Willie's brain hemorrhage kept bleeding for more than 2 days before a neurologic consult was scheduled
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
January 01, 2005 - finding, 5 (1%) missed by poor fine-needle
biopsy
Kawalski RG
(2004)
Aneurysmal
subarachnoid
hemorrhage … Diagnosis error case vignettes
Case 1
A 25-year-old woman presents with crampy abdominal pain, vaginal bleeding … Initial
misdiagnosis and outcome after subarachnoid
hemorrhage. JAMA 2004;291:866–9.
23.