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  1. psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
    September 15, 2024 - 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 .
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33561/psn-pdf
    September 15, 2024 - serious reportable adverse events is widely accepted, there is variation in the types of events to include … Commonly accepted criteria include being usually preventable, causing serious harm or death, easily
  3. psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
    August 21, 2005 - that leads to the majority of serious or fatal vascular outcomes worldwide. 3  Anti-thrombotic agents include … Examples of specific indications include: VTE treatment vs atrial fibrillation treatment, using warfarin …    Prescriptions sent to retail pharmacies from hospitals at discharge or physician’s offices can include … Instead, current recommendations for patients with acute arterial occlusion include use of intravenous … limited stock. 28  Delivery of bedside discharge education should be free of distractions and should include
  4. psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
    February 26, 2025 - Resources Used and Skills Needed Important components of the innovation include the following: … Resources Used and Skills Needed Important components of the innovation include the following: … Resources that need to be in place include dedicated IT staff, training for all staff, EHR technology
  5. psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
    November 30, 2023 - Common causes or contributing factors include stress from illness, decreased oral intake with variable … reasons for this increase in hospitalizations are not well understood; however, proposed explanations include … physiologic insulin in accordance with ADA guidelines. 9   Leveraging the electronic health record (EHR) to include … These teams should include physicians, dieticians, pharmacists, nurses, and advanced practice providers
  6. psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
    September 25, 2024 - during GI endoscopy in children has been reported to range from 1.5-4.8%. 3 , 8,9  These adverse events include … spasm, bradycardia, hypotension, aspiration, and vomiting. 5 Risk factors for cardiopulmonary events include … ; and (3) Initiation of definitive management. 15  Barriers to successful completion of these steps include … requests, and repeated calls for interventions. 18,20  In contrast, examples of ideal communication include
  7. psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - available facility teams and resources for placement. 3,4,5 Enteral feeding access options broadly include … These include: the somewhat controversial “cut & push” method, 32 whereby a PEG tube <18 French (Fr) … usually due to loss of information or other problems in communication. 38-42 Contributing factors include … Additional complicating factors include various care locations, especially when multiple care teams are … These might include the processes and outcomes of building pathways and protocols, oversight committees
  8. psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
    July 01, 2011 - Safety events that may result from such behaviors include self-harm (e.g., suicide attempts), assault … The authors of this study include a list of the objects and structures in the unit that were used in … The medical evaluation of a patient with acute psychiatric complaint should include history, review of … Areas for improvement in patient safety within inpatient psychiatry include standardizing processes in … In addition, the commentary does not include information regarding investigational or off-label use of
  9. psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
    August 21, 2024 - Examples of confounding diagnoses include preeclampsia and other hypertensive disorders of pregnancy … for well over half of all severe maternal morbidities.( 16 ) The major causes of obstetric hemorrhage include … If bleeding is recognized, the standard next steps include administering secondary medications like methergine … In addition, the commentary does not include information regarding investigational or off-label use of
  10. psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
    May 11, 2014 - In addition, the transition of patients from the OR to inpatient units may include continuation of heparin … Ideally, a multidisciplinary assessment of heparin use in the OR would include anesthesiologists, surgeons … The goals of this assessment should include identification of unnecessary variation; agreement on how … several medication safety experts, specific recommendations to prevent heparin errors in the OR would include
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47262/psn-pdf
    August 22, 2018 - Responsibilities of a medication officer include serving as a champion, advocating for safety interventions
  12. psnet.ahrq.gov/periodic-issue/periodic-issue-469
    December 31, 2024 - Examples from health care include using AI to detect diagnostic errors and combining AI with clinician … Examples from health care include using AI to detect diagnostic errors and combining AI with clinician … The elements include promoting transparency, supporting safe cultures through partnership, and encouraging
  13. psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
    August 31, 2020 - support communication between patients and providers, but also to use that communication as a means to include … More discrete interventions include the use of discharge education programs and simplified discharge … Examples include:   Broad inclusion of interdisciplinary teams for intensive collaboration and the
  14. psnet.ahrq.gov/web-mm/2-week-itch
    June 16, 2019 - These include: similar dosage form (both available as a tablet); two strengths that are shared (5 mg … (Since Zyprexa is an antipsychotic, prescribers may be reluctant to include the purpose on prescriptions … Include purpose of medication on prescriptions.
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50756/psn-pdf
    December 18, 2019 - systematic review indicated that common barriers to prescribing naloxone in primary care settings include … This education should include how to recognize the signs and symptoms of overdose, in addition to how … These could include leveraging electronic medication ordering systems to emphasize need for pharmacist
  16. psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - Post-transplantation evaluation of graft dysfunction should include early efforts to rule out vascular … Early vascular complications that can occur within a week of transplant include vascular thrombosis, … Some of these potential changes include lowering the clinical threshold for imaging assessment of post-transplant
  17. psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
    February 23, 2022 - locked-in syndrome. 1, 2 The most common risk factors associated with rapid correction of hyponatremia include … The factors known to be associated with increased risk of incident ODS include alcoholism, malnutrition … For symptomatic hyponatremia, this order set would include laboratory assessment of serum sodium at frequent
  18. psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
    February 17, 2021 - 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
  19. psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
    December 02, 2020 - by the appropriate individuals.(4) However, without well-designed and rigorously tested systems that include … Safeguards should include both heightened situational awareness on the part of the clinicians caring … In addition, the commentary does not include information regarding investigational or off-label use of … Medications with Potentially Complex Dosing June 24, 2020 How often do prescribers include
  20. psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
    April 27, 2022 - Common challenges encountered include unstable Wi-Fi connections, lack of broadband access, limited digital … non-life-threatening, test results and/or not communicating these results to a patient—but they can also include … These steps include leveraging advances in HIT to support or refute unexpected lab findings; using tracking … Potential benefits of these projects include renewed interest in new and well-established patient safety

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