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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
October 01, 2011 - www.ncbi.nlm.nih.gov/pubmed/18283429
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Role of Therapy Services
Rehabilitation services often include … Physical Therapy in the ICU
Interventions may include:
Positioning
Postural drainage
Airway clearance … Interventions include patient-specific exercises that increase flexibility, teach new movement strategies … These benefits include fewer short- and long-term complications, and reduced length of stay.
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - 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 … and 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
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - read-back techniques
Opportunities for the receiver to review relevant patient historical data, which may include … face-to-face verbal report on the patient should be required of EMS providers
This verbal report should include … Commission Patient Safety guidelines
ED-to-inpatient provider signout should be brief but thorough and include … Information to Include in ED-to-Inpatient Handoff
Presenting complaint and history of present illness … Take-Home Points (2)
The handoff between the ED and inpatient teams should be brief but standardized to include
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - The indications for tracheostomy include upper airway obstruction (e.g., obstructive sleep apnea; stridor … to head/neck surgery or trauma. 4 The benefits of tracheostomy, compared with endotracheal tubes, include … endotracheal tubes before tracheostomy. 8 Modifiable care-related risk factors for tracheal fistulas include … broader hospital standards. 13,14 Tracheostomy teams can be structured in different ways and often include … Policy and staff education should include airway cuff pressure monitoring technique and protocols.
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - addition, there are several suspected diagnoses that require urgent
evaluation and imaging; these include … – These include new urinary retention, fecal incontinence, saddle anesthesia,
history of intravenous … factors outside the control of the
physician or the healthcare system
– System-related errors, which include … technological or organizational
barriers
– Cognitive errors, which include inadequate knowledge, poor … Tactics to prevent pain management from becoming
adversarial include early and frequent communication
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psnet.ahrq.gov/node/47675/psn-pdf
November 28, 2023 - Topics covered include organizational characteristics
required for successful web-based distribution
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psnet.ahrq.gov/node/36110/psn-pdf
April 04, 2024 - The data
and graphs are updated regularly and include a 10 year trend analysis and specific analysis
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psnet.ahrq.gov/node/33895/psn-pdf
April 01, 2024 - Updates to the survey include increased time allotted to
complete computerized provider order entry
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psnet.ahrq.gov/node/866357/psn-pdf
July 24, 2024 - psnet.ahrq.gov/issue/peoples-experiences-diagnosis
The discussion of diagnostic safety has expanded to include
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psnet.ahrq.gov/node/836934/psn-pdf
March 12, 2025 - The top ten concerns for 2025 include poor response to patient and family concerns, oversight of artificial
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psnet.ahrq.gov/node/867347/psn-pdf
December 11, 2024 - embedding artificial intelligence (AI) into daily care, this commentary
outlines recommendations that include
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psnet.ahrq.gov/node/47847/psn-pdf
July 10, 2024 - Sections of the report include high-level review of falls and inequities, medication safety issues, syphilis
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - quitting or replacing smoking with a less harmful nicotine delivery system.( 3,4 ) The potential risks include … the US, the use of e-cigarettes is prohibited wherever smoking tobacco is not allowed, which would include … Public Health England recommendations include the use of e-cigarettes to support tobacco control policies … Most hospitals in the United States include e-cigarettes in smoke-free policies that were developed for … Where smoke-free policies include banning the use of e-cigarettes, all cigarette smokers and e-cigarette
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - with up to one-third of these errors leading to observed patient harm. 2,3 The most common errors include … with a way to examine their medication safety practices, and The Joint Commission (TJC) continues to include … Common strategies to differentiate between products (i.e. look-alike sound-alike medications) include … Solutions may vary but can include documenting waste via automated dispensing cabinets or directly in … Challenges include but are not limited to 16
Decreased access to clinical decision support tools
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - team report that to lead and implement the initiative organizations need multidisciplinary teams that include … Important strategies include identifying early the social determinants of health risk factors, identifying … team report that to lead and implement the initiative organizations need multidisciplinary teams that include … Important strategies include identifying early the social determinants of health risk factors, identifying
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - The resulting strengths of RIC go beyond a more traditional M&M model and include improvements to communication … Planning and Development Process
Key steps in planning and implementing the innovation include: Identifying … Some recommendations include the vice chair of surgical quality, or any surgeon, anesthesiologist, or … At the innovating organization, all M&M reviews include the core principles of the RIC—namely, review
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psnet.ahrq.gov/node/33581/psn-pdf
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)
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psnet.ahrq.gov/node/50581/psn-pdf
October 23, 2019 - Key concerns highlighted include inadequate surgical stapler use and lack of point-of-care ultrasound
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psnet.ahrq.gov/node/860400/psn-pdf
January 10, 2024 - Educational mechanisms include
collaboratives, videos and "Safety Speaks" podcasts.
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psnet.ahrq.gov/node/856640/psn-pdf
November 29, 2023 - Data reviewed include cesarean and pediatric regional anesthesia incidents submitted to
webAIRS over