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61. Retained Surgical Items: Definition and Epidemiology. | PSNet
    psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
    September 15, 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, vessel

62. Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet
    psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Updates include expanded use by other organizations, expanded description of the innovation, additional … The eight risk factors for readmission (8Ps) include (1) problems with medications, (2) psychological … These include general clinical conditions since discharge, medication reconciliation, and follow-up plans … At a minimum, these rounds should include members of the immediate care team (e.g., physicians, bedside … Selected elements of the planning and development process described by the guide include the following

63. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73300/psn-pdf
    July 01, 2022 - Updates include expanded use by other organizations, expanded description of the innovation, additional … The eight risk factors for readmission (8Ps) include (1) problems with medications, (2) psychological … These include general clinical conditions since discharge, medication reconciliation, and follow-up … Selected elements of the planning and development process described by the guide include the following … Process measures might include patient/family caregiver understanding of treatments, follow-up care

64. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38863/psn-pdf
    August 12, 2009 - The integral components of an effective signout include providing accurate and updated information, … Unfortunately, this mixed-methods study found that most resident handoffs did not include these key

65. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - • Critical situations where IO access is commonly utilized include cardiopulmonary arrest, shock, … – Other potential advantages of humeral IO placement include decreased pain, higher first attempt … – Other complications include osteomyelitis, skin abscess, bone fracture, and cellulitis, although … • Clinical signs of compartment syndrome include tenseness or firmness of the involved compartment … These errors include: – Incomplete penetration of the bone cortex – Penetration of the needle through

66. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43474/psn-pdf
    August 28, 2017 - The authors found that safety research does not uniformly include ethnically diverse populations or … characterization of the role disparities play in adverse events, the authors call for research to include

67. Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care | PSNet
    psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
    July 23, 2024 - However, all projects seek to include a multidisciplinary team wherever possible. … However, all projects seek to include a multidisciplinary team wherever possible. … Include a social incentive. … Social incentives include collaboration, competition, and support and help to reinforce behavioral change … Examples of Nudge Unit projects with a patient safety component include: Using default options to

68. Transition to Nowhere | PSNet
    psnet.ahrq.gov/web-mm/transition-nowhere
    March 21, 2009 - 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

69. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49808/psn-pdf
    October 01, 2017 - patients (25%) experienced 139 unexpected events.(6) The primary reasons for these adverse events include … For example, interdisciplinary communication to radiology might include critical medication issues, … Pretransfer activities should also include both the transfer coordination and the testing and use of … Relevant to this case, such information might include warnings on the pump display and in the EHR about … Interdisciplinary communication should be expanded to include critical patient safety information.

70. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33603/psn-pdf
    September 15, 2024 - The most common types of inpatient surgical procedures include obstetrical procedures (e.g., cesarean … Risk factors for SSI include patient factors (such as age, tobacco use, diabetes, and malnutrition) and … Key elements of successful organizational interventions to prevent SSIs (and HAIs in general) include … standardize safety assessment and improve teamwork and communication in surgical care, and also generally include

71. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867359/psn-pdf
    December 18, 2024 - Several other aspects of this case include the potential to give an exclusively breastfeeding mother … Recommended best practices include electronic scanning to validate and decrease errors.14 When performing … staff or nurses are recommended to be included in training on standardized processes for tasks that include … Best practices for communicating after patient safety errors have occurred may include the following: … 21 Preparing for the discussion, including considering where to have the conversation and who to include

72. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - Opportunities for the receiver to review relevant patient historical data, which may include previous … Examples of such checklists include an inpatient signout template highlighted in a previous AHRQ WebM … These "ring downs" are necessarily brief, do not include identifying information (beyond patient age … EMS "runsheets" (EMS provider documentation of the patient encounter) are designed to include these … In addition, his commentary does not include information regarding investigational or off-label use

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49545/psn-pdf
    September 01, 2007 - Risk factors for suffering an acute MI during the procedure include recent unstable angina or non–Q-wave … Symptoms include urticaria, angioedema, bronchospasm, and hypotension. … Symptoms, signs, and laboratory abnormalities that should raise suspicion of retroperitoneal bleed include … Findings suggestive of pseudoaneurysm at the puncture site include pulsatile mass, extreme tenderness … Vascular complications are the most common, although other complications include procedure- associated

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49804/psn-pdf
    September 01, 2017 - Common causes of upper GIB include erosive disease, ulcers, varices, and angioectasias.(4) Common causes … The history should include color, volume, and frequency of bleeding, a review of comorbid conditions … Laboratory evaluation should include a complete blood count, comprehensive metabolic panel, coagulation … Clinical factors that point to the upper track being the source of a GIB include melena, nasogastric … associated with higher mortality include advanced age, comorbidities, presentation with melena, onset

75. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42548/psn-pdf
    December 29, 2014 - 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

76. Patient Safety in Medical, Nursing, and Other Clinical Education | PSNet
    psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
    January 31, 2020 - Areas of focus include knowledge of common causes of errors and how to avoid them, attitudes towards … Include medical educators on sentinel event task forces or committees.  … Recommendations from these articles, as well as from adult learning theory and research, include: Wherever … Courses that include both didactic and “learn by doing” components are successful at teaching students … Examples of QIPS competencies include those that focus on: Improving individual safety practices, such

77. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60044/psn-pdf
    March 16, 2020 - Areas of focus include knowledge of common causes of errors and how to avoid them, attitudes towards … Recommendations from these articles, as well as from adult learning theory and research, include: Figure … Include medical educators on sentinel event task forces or committees.  … Courses that include both didactic and “learn by doing” components are successful at teaching students … Examples of QIPS competencies include those that focus on: Improving individual safety practices, such

78. Check Twice, Transport Once | PSNet
    psnet.ahrq.gov/web-mm/check-twice-transport-once
    March 15, 2023 - 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 … These errors include transporting the wrong patient, transporting to the wrong location, communication … The consequences of these errors include patient harm, delays in care, increased healthcare costs, and

79. Surgical Site Infections | PSNet
    psnet.ahrq.gov/primer/surgical-site-infections
    December 15, 2024 - The most common types of inpatient surgical procedures include obstetrical procedures (e.g., cesarean … Risk factors for SSI include patient factors (such as age, tobacco use, diabetes, and malnutrition) … Key elements of successful organizational interventions to prevent SSIs (and HAIs in general) include … standardize safety assessment and improve teamwork and communication in surgical care, and also generally include

80. Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - Tube: Indications, Insertion Methods, Potential Complications (1) • Indications for NGT placement include … standard” for confirming appropriate tube placement in adults.5-7 – Alternate NGT insertion methods include … Indications, Insertion Methods, Potential Complications (4) • Contraindications to blind NGT insertion include … • NGTs should be routinely assessed every 2 to 4 hours for appropriate placement.14-15 Assessments include … ability to observe patients, which may cause safety issues.20 • Methods to mitigate these problems include