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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - ACGME requirements will enhance patient safety by expanding the boundaries of resident education to include … These would include appropriate safeguards, such as review of pre-procedure imaging studies by a competent … Exceptions include patients with large, free-flowing effusions who have successfully undergone serial
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psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - Common adverse effects of sleep aids include residual daytime sedation leading to increased risk for … Other common factors that contribute to poor outcomes with sleep aid use include inappropriate administration … such as loud noise, bright lights, and night staff disruptions.( 9 ) Interventions to reduce noise include
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Both doctors and nurses recounted professional requests for health care "favors" include taking blood … Justifications for such requests include long work hours, difficulty accessing care when off-duty, distrust … Additionally, failing to include nursing in procedures exposes patients to risks of injury related to
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - Aspects of the patient's habitus that may present a challenge include (but are not limited to) obesity … Reasons for ordering an emergent consultative echocardiogram include, but are not limited to, hemodynamic … These methods may include but are not limited to a question bank, a quality assurance process, direct … In addition, the commentary does not include information regarding investigational or off-label use of
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Postanalytic errors occur after production of a laboratory result and include errors associated with … were not successfully communicated to hospital staff.( 8 ) Other examples of previous Q probes studies include … Examples of ongoing Q tracks programs include monitoring errors in patient wristbands, blood culture … interventions to reduce errors in laboratory services.( 14 ) “Weak” interventions, which are not shown, include
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Hallmark signs include an abrupt change in cognition, variability in level of consciousness, and disrupted … monitoring Haloperidol 0.25–0.5 mg orally or intramuscularly twice daily is preferred; adverse effects include … prolongation Atypical antipsychotics (e.g., quetiapine, risperidone, olanzapine); adverse effects include … Benzodiazepines should only be reserved for treatment of alcohol or benzodiazepine withdrawal; adverse effects include
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psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
March 01, 2004 - CT characteristics associated with a benign etiology include smaller size, fat density, or a central, … CT characteristics associated with malignancy include larger size, upper lobe location, irregular margins … Patient-specific risk factors for malignancy include older age, current or former smoking status, prior … In addition, the commentary does not include information regarding investigational or off-label use of
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - primary care team's rationale for their actions.( 12 ) In the case above, the primary team's failure to include … Assessing Competence at Handoffs Although approaches to assessing handoff competence can include simulation … Their commentary does not include information regarding investigational or off-label use of pharmaceutical … above case, attending could say, "When you hand off this patient later today, what is important to include
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - The Canadian Quality and Patient Safety Framework for Health Services and its goals for safe care include … Common features include enhancing patient and caregiver engagement, tracking and sharing safety data,
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Examples of these
advantages include: averting problems with handwriting, similar drug names, drug interactions … Promising error reduction strategies in the setting of dispensing and administration include involving
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - repairs.3
Planning and Development
The keys to success of any patient safety innovation or intervention include … and skills used to support implementation of this innovation are as follows:
Essential team members include
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - concerning, falls also extract an increasingly large cost on health care providers—financial consequences include … Components most often seen in successful trials include:
Multidisciplinary (rather than solely nursing … Forward
For any health care organization seeking to renew its efforts to prevent falls, key steps include
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - Resources Used and Skills Needed
Important components of the innovation include the following: … by 21%. 6
Planning and Development Process
Key steps in planning and implementing the innovation include … the A-F bundle together
Resources Used and Skills Needed
Important components of the innovation include
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Errors in care
and adverse events associated with health literacy include mistakes in diabetes management … Improve Spoken Communication: Organizations’ health literacy plans include processes to
ensure clear
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - Other organizational and environmental factors that play an important role in diagnostic error include … practitioners. 5 Reducing Diagnostic Error System-level interventions to reduce diagnostic errors may include … prognostic factor for both small bowel 20 and colonic perforations. 21 Other identified risk factors include … better served with an initial damage control laparotomy. 25 The principles of damage control surgery include
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - this may be lower than actual values given the challenges with access to data. 2 These conditions include … These outcomes can include a higher likelihood of neglecting medical care, worsening of pre-existing … Follow-up care should be personalized to the patient's needs and may include regular check-ins, medication … The perinatal mental health conditions in the bundle include but are not limited to depression, anxiety … In our readiness element, we include providing training and education to address racism, healthcare team
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psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - Several commonly used diagnostic imaging techniques include computed tomographic (CT) scans, fluoroscopy … Prominent national examples include the Image Wisely campaign and the pediatric initiative, Image
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - patients with AD reported no pain.( 9 ) Physical findings that may support the presence of a dissection include … Problems degrading the test characteristics of the chest x-ray in this setting include vagaries in the … Related cognitive biases include "framing" (we are overly biased by the way in which a case is presented … In addition, his commentary does not include information regarding investigational or off-label use of
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - In this area, best practices include the following: First, a centralized staffing office that assists … Solutions that are commonly used include: (i) reassigning a nurse from another comparable unit where … Take-Home Points
Best practices in dealing with nurse staffing ratios include:
Conduct failure … In addition, her commentary does not include information regarding investigational or off-label use of
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - Symptoms and signs that may indicate another cause include nausea and vomiting persisting past mid-pregnancy … Warning signs include pain that is localized, abrupt, constant, or severe, or pain that is associated … In addition, the commentary does not include information regarding investigational or off-label use of