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41. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73469/psn-pdf
    July 07, 2021 - Benefits include humanization of the patient and improved patient safety; barriers include provider

42. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866404/psn-pdf
    July 31, 2024 - patient-and-caregiver-perspectives-causes-and-prevention-ambulatory- adverse-events Adverse event (AE) investigations typically only include … Themes identified include: (1) patients and teams have specific safety responsibilities; (2) proactive

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47776/psn-pdf
    August 20, 2021 - Recommendations for patients who may seek to have robotically assisted surgery include asking about … Suggestions for health care providers include completing specialized training on procedures they perform

44. What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. | PSNet
    psnet.ahrq.gov/issue/what-known-about-adverse-events-older-medical-hospital-inpatients-systematic-review
    January 12, 2012 - The studies had varying definitions of adverse events; for example, some did not include geriatric syndromes … The authors argue that the standard definition of adverse events affecting geriatric patients should include

45. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/862154/psn-pdf
    June 18, 2020 - Recommendations for providers include the inclusion of patients as partners in decision making and spending … Recommendations for health care systems include implicit bias training and education to reduce judgment

46. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/860015/psn-pdf
    September 01, 2024 - Examples include ingested batteries, dentures, safety pins, screws and other sharp objects, inserted … Surgical sponges include but are not limited to laparotomy pads (18”x18”), mini laps (12”x12”), baby … Sharps Metallic, pointed or cutting objects of various sizes that include but are not limited to suture … Examples include, but are not limited to clamps, needle holders, multi-component retractors, malleable … Devices include items such as staplers, drains, catheter insertion sets, needle localization sets,

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - procedure across all acute and chronic care settings.1 Indications for nasogastric tube placement include … neurologically impaired, and delivery of enteral nutrition.1 Contraindications to NG tube placement include … The American College of Radiology’s practice parameters (formerly guidelines) include contacting ordering … Tools to improve timely and accurate exchange of information include closed loop communication (CLC) … Tools that may be utilized include closed loop communication, I-PASS handoff template, automated methods

48. Patient Safety in Primary Care | PSNet
    psnet.ahrq.gov/perspective/patient-safety-primary-care
    January 31, 2020 - The examples highlighted in 2019 and in this essay include: Inappropriate and overprescribing … These include surveillance approaches, such as automated phone calls, that target patients prescribed … Comprehensive care transformation efforts, such as patient-centered medical homes , that include care … coordination embedded within their framework and may even include financial incentives. … Other initiatives practices may consider include interactive educational webinars, provider coaching,

49. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49853/psn-pdf
    February 01, 2019 - These include communication breakdowns, lack of assessment of patient pre- and post-intrahospital transfer … During the intrahospital transfer, the checklist may include checking and recording the patient's vital … After the intrahospital transfer, the checklist may include reassessment of patient condition, a reminder … it occurs across professions and support staff within a setting.(10) Barriers to speaking up might include … health care teams is often unclear.(11) Improving safety climate among all health care providers might include

50. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50927/psn-pdf
    February 21, 2020 - disease, cancer, and respiratory disease.[2] Important services delivered by primary care clinicians include … The examples highlighted in 2019 and in this essay include: Inappropriate and overprescribing Poor … These include surveillance approaches, such as automated phone calls, that target patients prescribed … Examples include, but are not limited to: Automated alerts when patients are hospitalized to ensure … coordination embedded within their framework and may even include financial incentives.

51. Medication Administration Errors | PSNet
    psnet.ahrq.gov/primer/medication-administration-errors
    December 15, 2024 - Therefore, four additional “rights” were proposed to include right documentation, action/reason, form … System-related causes of medication administration errors may include inadequate training, distractors … Contributing factors to patient and caregiver error include low health literacy , poor provider–patient … Independent double checks should include “walking” or tracing the infusion lines from the infusion pump … Challenges include keeping DERS in the smart pump aligned with most current hospital practice, ensuring

52. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33605/psn-pdf
    March 12, 2021 - Therefore, four additional “rights” were proposed to include right documentation, action/reason, form … System-related causes of medication administration errors may include inadequate training, distractors … Contributing factors to patient and caregiver error include low health literacy, poor provider–patient … Independent double checks should include “walking” or tracing the infusion lines from the infusion pump … High Tech Solutions High-tech solutions commonly implemented within health systems include: barcode

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49867/psn-pdf
    July 02, 2019 - Other adverse effects include hypokalemia, hypomagnesemia, and hypercalcemia. … body of research has identified risk factors.(2,4,5,8) The most common nonmodifiable risk factors include … reproducibility of hyponatremia on single-dose thiazide rechallenge.(2,9) Modifiable risk factors include … The main adverse effects of thiazides include hyponatremia, hypokalemia, hypomagnesemia, and hypercalcemia … In addition, the commentary does not include information regarding investigational or off-label use

54. ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay | PSNet
    psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-nursing
    October 30, 2024 - Responsibilities primarily include confirming which patients are to be discussed during the weekly meetings … At the SNFs, teams include physicians, nurse practitioners, physical therapists, social workers, and … discharge medication lists to SNF-administered medication records. 2   Discussions between the teams include … Additional key steps include core program planning, such as creating a budget and securing the necessary … Responsibilities primarily include confirming which patients are to be discussed during the weekly meetings

55. Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. | PSNet
    psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
    November 15, 2023 - Updates include expanded use by other organizations, additional results, revisions to innovation description … General resources required include: Staffing:  One team can manage a daily census of 5 to 8 patients … Additional diagnostic studies that are performed in the home include basic radiography such as chest … Eligible patients include those who require hospitalization for a condition such as community-acquired … Common reasons for medical ineligibility include uncorrectable hypoxemia (insufficient oxygen in the

56. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49730/psn-pdf
    April 01, 2015 - From the patient perspective, barriers to an effective care transition could include poor understanding … From the provider perspective, barriers to an effective care transition often include poor knowledge … most impactful in reducing hospital readmission rates.(4) Transitional care models, which generally include … The need to include training to facilitate effective care transitions (12,13) is a critical and often … New models of care such as the Patient-Centered Medical Home that include new types of health care workers

57. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836978/psn-pdf
    May 16, 2022 - transportation, either pre-, intra-, or post-transportation.2,4 Errors involving communication can include … Other types of errors involving patient transport include equipment malfunction, displacement of indwelling … flow, which can compromise patient safety.5-6 Finally, physiologic deterioration in transport can include … In addition to these workflows, recommendations to optimize intrahospital transport include thorough … The consequences of these errors include patient harm, delays in care, increased healthcare costs, and

58. Adverse Event During Intrahospital Transport | PSNet
    psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
    June 16, 2021 - These include communication breakdowns, lack of assessment of patient pre- and post-intrahospital transfer … Possible safety solutions include the use of checklists, specific training programs, and technical interventions … During the intrahospital transfer, the checklist may include checking and recording the patient's vital … After the intrahospital transfer, the checklist may include reassessment of patient condition, a reminder … it occurs across professions and support staff within a setting.( 10 ) Barriers to speaking up might include

59. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45013/psn-pdf
    April 13, 2016 - Recommendations include expanding the definition of adverse reaction to include medication errors and

60. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
    November 01, 2011 - patient, but do not * * Background: Near Miss (2) Near misses are also called close calls Include … Examples include: Charting of vital signs in OR by anesthesiologists Systematic recording of erroneously … for medication administration * * * Managing This Case A formal review and analysis should include … documented and recorded (then analyzed with other similar incidents) A detailed investigation should include … Patient safety committee recommended that: Ordering template for “bedside” medications be modified to include