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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - the dynamic of being in a room all day with patients, one after another after another, followed by hours
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - generally employed relatively short observation periods ( 2,7 ); however, electronic counters record 24 hours
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psnet.ahrq.gov/node/33799/psn-pdf
January 01, 2015 - Burnout Among Health Professionals and Its Effect on
Patient Safety
January 1, 2015
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
Annual Perspective 2015
Bur…
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - All too often clinicians
come into a room they hadn’t visited in a couple of hours to find their patient … The standard is
to check vital signs intermittently every four hours.
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - After 72 hours, the intern was reminded that a patient had a urinary catheter. … did not yet have CPOE (we do now), so we used a written reminder where a nurse went around after 48 hours
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psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - ophthalmic ointment to the eye and affected lashes, patch the eye closed, and arrange for follow-up in 24 hours
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - She was scheduled for a repeat scan approximately 48 hours later, when her hCG would be expected to be
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psnet.ahrq.gov/web-mm/transition-nowhere
March 21, 2009 - Transitional care models, which generally include two or more interventions (e.g., telephone contact within 48 hours
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - result, the patient became drowsy with mild nausea and hypotension, but the symptoms resolved within 24 hours
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - The effect of extended work hours on patient care provided by medical interns.
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - Within 4 hours of beginning the lipid emulsion administration through the TPN line using a smart pump
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - quickly switched to the true IDs, but the timing for such corrections can range from 30 minute to 23 hours
-
psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - unstable spine fracture
16
Approach to Improving Safety & Patient Safety Target (2)
– Within Hours
-
psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Expedite the RCA process
An RCA2 review should be started within 72 hours of recognizing that a
review
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - Two hours after arriving, while the patient was still groggy from anesthesia, a nurse entered the room
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - of severe community acquired pneumonia who fail to show a response to treatment within the first 48 hours
-
psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - asking concrete questions, such as "tell me about all the medications you have
taken in the last 24 hours
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
February 01, 2010 - obstetrician reporting that the patient had delivered a healthy baby girl by Caesarian section in the early hours
-
psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - The final report of the patient's ultrasound, which returned many hours later, read, "deep vein thrombosis
-
psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Less than 24 hours after
admission to the ICU, the patient was extubated and died shortly thereafter