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Total Results: 9,165 records

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121. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50767/psn-pdf
     August 12, 2024 - Topic tracks for the session include workforce and patient safety, leadership and equity.

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867676/psn-pdf
     February 26, 2025 - Steps in responding to patient safety events include reporting, investigation, communication, remediation … As described in the CANDOR toolkit, components of an apology should include acknowledging the gaps in … Other improvement efforts include continuing education of health professionals through simulation, morbidity

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33590/psn-pdf
     September 15, 2024 - Quality and Safety Activities All hospitals are overseen by a board of directors, whose responsibilities include … These practices include structured use of data to enhance care by setting specific quality goals and … organizations that have transformed their practices and organizational culture to emphasize patient safety include

124. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72760/psn-pdf
     September 30, 2024 - Topics covered include electronic health records documentation, patient partnership and rural health

125. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73902/psn-pdf
     September 29, 2021 - Stage II progresses to include stabbing or shooting radicular pain, nuchal rigidity/neck stiffness, and … Additional symptoms may include fever, chills, numbness, weakness, or bladder or bowel dysfunction. … At minimum, this should include complete vital signs, direct visualization of the skin, palpation of … Advanced neurologic deficits may include paraparesis and quadriparesis, but these are late-stage findings … : Failure to include SEA in the differential diagnosis at each visit, which may exemplify availability

126. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome | PSNet
     psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
     April 27, 2022 - Stage II progresses to include stabbing or shooting radicular pain, nuchal rigidity/neck stiffness, and … Additional symptoms may include fever, chills, numbness, weakness, or bladder or bowel dysfunction. … At minimum, this should include complete vital signs, direct visualization of the skin, palpation of … Advanced neurologic deficits may include paraparesis and quadriparesis, but these are late-stage findings … : Failure to include SEA in the differential diagnosis at each visit, which may exemplify availability

127. Specimen Almost Lost | PSNet
     psnet.ahrq.gov/web-mm/specimen-almost-lost
     September 21, 2022 - This may include when specimens come from unusual locations, rare tests are ordered, or special care … Other risk factors for specimen loss or misprocessing include reliance on individuals to do the right … should be considered, including those that may be costly, such as an overhaul of the EHR and LIS to include … accessioned manually, risks associated with human error remain.( 6 ) Less costly systems solutions include … specimen time outs, which can be embedded into surgical or clinical checklists.( 7 ) The time out may include

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72587/psn-pdf
     December 23, 2020 - physical movement of critically ill patients is fraught with potential safety risks.1-4 These risks include … This team communication should, for example, include specifically asking “What might go wrong and what … Transport teams should include personnel with expertise in preventing perturbations in physiological … This process should include consideration of any available bedside alternatives.  … These activities should be supported by clear institutional guidelines and/or protocols that include

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866569/psn-pdf
     September 01, 2024 - Topics covered include medication safety, safe patient handling and safe surgical attire. 

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40460/psn-pdf
     April 30, 2024 - Additional topics covered include patient communication, publication, and learning management system

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49840/psn-pdf
     September 01, 2018 - Specific prophylactic approaches to reduce immunosuppression-related adverse effects include treatments … The most effective care transitions interventions span the entire transitional period and include elements … Common adverse effects with longer-term corticosteroid exposure include Cushingoid appearance, osteoporosis … The most common errors made in prescribing corticosteroids include issues with tapering, drug choice … In addition, the commentary does not include information regarding investigational or off-label use

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836976/psn-pdf
     April 27, 2022 - when IV access fails or is not feasible.1 Critical situations where IO access is commonly utilized include … For all patients, specific clinical signs of compartment syndrome include tenseness or firmness of the … In an awake and alert patient, reported symptoms include pain (often characterized as out of proportion … These errors include incomplete penetration of the bone cortex, penetration of the needle through the … At minimum, this should include a neurovascular exam and palpation of the limb’s compartment for the

133. Intraosseous Line Extravasation in a Pediatric Trauma Patient | PSNet
     psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
     September 29, 2021 - /min through a tibial IO line, respectively. 12 Other potential advantages of humeral IO placement include … For all patients, specific clinical signs of compartment syndrome include tenseness or firmness of the … In an awake and alert patient, reported symptoms include pain (often characterized as out of proportion … These errors include incomplete penetration of the bone cortex, penetration of the needle through the … At minimum, this should include a neurovascular exam and palpation of the limb’s compartment for the

134. Medication Errors and Adverse Drug Events | PSNet
     psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
     December 15, 2024 - Other well-documented patient-specific risk factors include limited  health literacy  and numeracy (the … These include medications that have dangerous adverse effects, but also include  look-alike and sound-alike … These  medications include  antidiabetic agents (e.g., insulin), oral anticoagulants (e.g., warfarin

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866528/psn-pdf
     August 14, 2024 - Tactics emphasized include caution regarding use of household spoons to dose liquid medications.

136. Mobility Lost in the ICU | PSNet
     psnet.ahrq.gov/web-mm/mobility-lost-icu
     August 01, 2018 - Interventions include patient-specific exercises that increase flexibility, teach new movement strategies … The resulting plan of care may include exercises that foster beneficial physical adaptations through … These benefits include fewer short- and long-term complications, and reduced length of stay. … In addition, the commentary does not include information regarding investigational or off-label use of … When patients can follow simple commands, interventions can include active-assisted and active range

137. A Room Without Orders | PSNet
     psnet.ahrq.gov/web-mm/room-without-orders
     September 01, 2011 - These actions usually include verifying admission orders, obtaining an admission history, performing … Responsibilities include ensuring adequate staffing to meet day-to-day care demands and facilitating … Potential strategies include: (i) establishing routine shift-to-shift communication about admissions … If nurses are changing shift during an admission, an ideal system would include standardized handoff … A well-designed system would also include a contingency plan for times of unanticipated stress such as

138. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation | PSNet
     psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
     June 28, 2023 - Contraindications to blind NGT insertion include facial or skull base fractures; head, neck, or esophageal … insertion, and may experience worsening confusion. 8 Complications associated with blind NGT insertion include … NGTs should be routinely assessed every 2 to 4 hours for appropriate placement. 14,15 Assessments include … ability to observe patients, which may cause safety issues. 20 Methods to mitigate these problems include … evidence of SBO on imaging, an NGT is probably no longer needed. 2 Other reasons for discontinuation include

139. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848110/psn-pdf
     April 26, 2023 - These include internal individual patient factors and external factors, such as the physical environment … and culture of care in the community.4-6 Internal functional factors include gait changes, and loss … Additional internal factors include mental health issues such as fear of falling, cognitive impairment … External factors include the culture of safety—described as the positive and negative ways safety is … incorporate input from all members of the interdisciplinary team.11,12 These approaches generally include

140. A Loss of Trust and a Missed Diagnosis | PSNet
     psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
     October 31, 2023 - In addition, there are several diagnoses that require urgent evaluation and imaging; these include cauda … These include new urinary retention, fecal incontinence, saddle anesthesia, history of intravenous drug … Pain management includes analgesia but must also include a thorough diagnostic workup to ensure underlying … technological or organizational barriers Cognitive errors, which include inadequate knowledge, poor … Tactics to prevent pain management from becoming adversarial include early and frequent communication