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psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - focused on handoffs.( 1 ) Responding to the increased frequency of resident handoffs created due to duty hours
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - surge of critically ill patients to care for and a shortage of personal protective
equipment, long hours
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - The patient reportedly had not taken his beta-blocker in the 36 hours prior to admission.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - medications daily in the hospital
Performed predischarge bedside counseling
Contacted patient 48 hours
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - the boy was given free water intravenously to correct severe hypernatremia, which took more than 48 hours
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Because PCI had been delayed for many hours from the time of the original STEMI, the patient experienced
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psnet.ahrq.gov/node/851555/psn-pdf
July 31, 2023 - psnet.ahrq.gov//#9
https://psnet.ahrq.gov//#9
findings but without a definitive diagnosis within 24-48 hours
-
psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - communicate only the first elevated result for a patient within a defined period of time (say, 24 or 48 hours
-
psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - If, for example, many PCPs affiliated with the same hospitals would have limited office hours on
the
-
psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - 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/its-all-syringe
February 01, 2013 - The patient was given orange juice, a sandwich, and his blood sugars were closely monitored for 4 hours
-
psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - asking concrete questions, such as "tell me about all the medications you have taken in the last 24 hours
-
psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - both sides of the stethoscope can easily access information critical to diagnosis and treatment at all hours
-
psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Justifications for such requests include long work hours, difficulty accessing care when off-duty, distrust
-
psnet.ahrq.gov/web-mm/collegiality-vs-competence
August 28, 2024 - The patient was finally closed and transferred to the ICU 6 hours after the DIC was first noted.
-
psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
-
psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
-
psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
-
psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
-
psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight
in Cardiac Surgery
April 24, 2024
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…