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  1. psnet.ahrq.gov/issue/creating-just-culture-perioperative-setting
    July 13, 2009 - Strategies include creating an accessible reporting system, implementation of a " good catch " program
  2. psnet.ahrq.gov/issue/improving-diagnosis-health-care
    September 12, 2018 - Longer-term recommendations include establishing a work system and safety culture that foster timely
  3. psnet.ahrq.gov/issue/society-critical-care-medicine-guidelines-recognizing-and-responding-clinical-deterioration
    April 24, 2018 - Recommendations include organization-wide rapid response team activation criteria, patient deterioration
  4. psnet.ahrq.gov/primer/debriefing-clinical-learning
    September 15, 2024 - Examples include a one-on-one discussion with a healthcare professional who made a medical error or discussing … Historically, debriefing evolved from post-mission analysis of military or police actions and grew to include … Techniques of debriefing vary, but usually include an emotional release component, a review of the facts … Common methodologies for debriefing include: Plus-delta: a straight-forward approach that asks learners … Considerations for the type of debriefing to hold may include the seriousness of the event, the number
  5. psnet.ahrq.gov/web-mm/elopement
    July 14, 2010 - Such preventive measures may include placing the patient on an observation protocol (special precautions … Such a protocol may include locating the patient close to the desk, placing an electronic monitoring … Additional precautions common in mental health and rehabilitation facilities include automatic door locks … Response to elopement by patients with diminished capacity should be immediate and include unit staff … In addition, the commentary does not include information regarding investigational or off-label use of
  6. psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
    December 23, 2020 - use of both generic and brand names for medications, it has become a suggested standard of care to include … team members involved with administration or prescription of medications, and that education should include … 17 of Title 16, California Code Regulations: 9   “(c) When oral consultation is provided, it shall include … or caregiver can reduce the risk of harm associated with the use of medication. 12  These “moments” include … are prescribed  Know the indication for which your medication is prescribed and have the prescriber include
  7. psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
    May 16, 2022 - These interventions include: patient education, medication reconciliation, ensuring follow-up appointments … asynchronous methods, and a high number of communication events. 30 Players crucial to the process include … with nurses and physicians. 31 Other members of multidisciplinary teams that play important roles include … from other disciplines relevant to the discharge process. 35   An effective discharge huddle should include … Empowerment is part of a broader focus on communication that should also include eliciting the patient
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - use of both generic and brand names for medications, it has become a suggested standard of care to include … team members involved with administration or prescription of medications, and that education should include … deems it warranted in the exercise of his or her professional judgment, oral consultation shall also include … or caregiver can reduce the risk of harm associated with the use of medication.12 These “moments” include … Medication Errors Know the indication for which your medication is prescribed and have the prescriber include
  9. psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
    February 19, 2020 - of falls result in injury.( 5 ) Common fall-related injuries associated with morbidity and mortality include … infarction, syncope, or a seizure; these account for 8% of all falls in the hospital.( 9 ) Preventable falls include … accidental falls (14%) and anticipated physiological falls (78%).( 9 ) Accidental falls include slips … Other strategies that have been used to manage disoriented patients include locating the patient in a … In addition, the commentary does not include information regarding investigational or off-label use of
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33573/psn-pdf
    March 15, 2025 - Although there is no standard definition of disruptive behavior, most authorities include any behavior … Other interventions to prevent disruptive behavior include measures to improve safety culture.
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867980/psn-pdf
    March 25, 2025 - Generic pitfalls include one condition repeatedly mistaken for another and a chronic disease mistakenly … For example, in patients with headache, important red flags that portend a serious diagnosis include … Such conditions (etiologies) in patients with headache include intracranial hemorrhage, CNS infections
  12. psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
    July 08, 2022 - when or if a subsequent opioid dose is safe to administer. 2 Other standardized sedation assessments include … Stacking” Additional factors to consider in the reassessment of a patient after opioid administration include … Risk reduction strategies pertaining to opioid dose stacking include incorporating institutional guidelines … Further steps in care include cardio-pulmonary resuscitation and naloxone administration as soon as possible … Additional strategies that may be employed by nurses to aid in short-term pain relief include mindfulness
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33594/psn-pdf
    November 18, 2021 - Examples include a one-on-one discussion with a healthcare professional who made a medical error or … Historically, debriefing evolved from post-mission analysis of military or police actions and grew to include … Techniques of debriefing vary, but usually include an emotional release component, a review of the facts … Common methodologies for debriefing include: Plus-delta: a straight-forward approach that asks learners … Considerations for the type of debriefing to hold may include the seriousness of the event, the number
  14. psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - Other factors commonly found in patients presenting for ECRP with an increased aspiration risk include … Other factors that increase aspiration risk include full stomach, incompetent lower esophageal sphincter … MAC can include all levels of sedation and patients may need airway intervention if deep sedation is … Some preemptive measures include thorough preoperative risk assessment and preoperative fasting. … In addition to visualization of gastric contents in the mouth or airway, other signs of aspiration include
  15. psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
    October 30, 2024 - Key results from implementation of the AAM program include lower mortality within 30 days of an alert … The RRT nurse then collaborates with the clinical team, which can include the hospitalist, bedside nurse … Key results and findings from the staggered implementation of the AAM program across 19 hospitals include
  16. psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
    August 15, 2018 - Risk factors for preeclampsia include nulliparity, chronic hypertension, previous preeclampsia, gestational … labor or rupture of membranes ( Figure ).( 1,2 ) As seen in this case, common errors in management include … These would include appropriate safeguards, such as standardized techniques for measurements of weight … facilities providing care for obstetric or postpartum patients should also develop mechanisms that include … They should also include procedures for regularly monitoring both adherence to protocols and quality
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50764/psn-pdf
    December 18, 2019 - This article shares reasons for these biases and shares tactics to minimize their impacts which include
  18. psnet.ahrq.gov/issue/world-health-organization-field-trial-assessing-proposed-icd-11-framework-classifying-patient
    December 29, 2014 - For the first time, the World Health Organization ICD-11 will include a taxonomy for quality and safety
  19. psnet.ahrq.gov/issue/racial-inequality-receipt-medications-opioid-use-disorder
    April 24, 2018 - Best practices for treating patients with opioid use disorder (OUD) include prescribing medications
  20. psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging
    June 16, 2011 - The domains that encompass provider attitudes include teamwork climate, safety climate, perceptions of

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