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psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
December 21, 2017 - patients (25%) experienced 139 unexpected events.( 6 ) The primary reasons for these adverse events include … such as radiology, despite the fact that such departments also require robust clinical handoffs that include … 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.
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - Persons at risk often include the elderly, those
who have a history of substance abuse, or those with … Additional structured assessment tools that can be used
include the Aid to Capacity Evaluation (ACE) … System barriers that must be overcome to appropriately address the question of mental capacity include … For example, teams that do not include a
social worker or mental health professional may not have the … A complete history must include a thorough psychosocial history to identify any potential
psychological
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - • Persons at risk often include the elderly, those who have a history
of substance abuse, or those … – Additional structured assessment tools that can be used include the Aid to
Capacity Evaluation … – For example, teams that do not include a social worker or mental health
professional may not have … • Useful teaching methods include some that raise awareness and
change attitudes (asking, promoting … Some challenges in
developing an outpatient palliative care program include inadequate
reimbursement
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psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - of universal precautions for HCWs to follow with all
patients, regardless of HIV status.(4) These include … or aerosolized particles.(1,5) Accordingly, CDC guidelines for controlling risk of VZV
transmission include … single patient rooms and a 3 feet minimum distance between all
patients; airborne precautions include … Risk factors may include travel history, sick contacts, occupation, and results from diagnostic testing … Key infection control program components include HCW immunization
verification, periodic immunity testing
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 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
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psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - estimated that 3% of admissions for DKA are consistent with eDKA.1
Precipitating factors for eDKA include … outcomes, the use of
SGLT2i is growing over time. 2,3,4
Risk factors for eDKA with these medications include … recommended for use in this patient population.6 Additional risk
factors for eDKA with SGLT2i use include … Components of this approach include:
1. … FDA revises labels of SGLT2 inhibitors for diabetes to include warnings
about too much acid in the blood
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - 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 … received a three-year Agency for Healthcare
Research and Quality (AHRQ) grant to expand the program to 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
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - Updates to the survey include increased time allotted to complete computerized provider order entry evaluation … Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing … Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired … Responsibilities of a medication officer include serving as a champion, advocating for safety interventions … Current IHI initiatives include a white paper collection, an international conference series, and an
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - 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 … In addition, his commentary does not include information regarding investigational or off-label use of … During the transition in care, verbal signout from ED providers to inpatient providers should include
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - Initial Evaluation in Suspected Stroke
Rapid and focused assessment is key
Primary elements should include … The elements help create a scoring system that guides assessment of neurologic impairment
Elements include … to treatment with intravenous rtPA
Strategies that can compress treatment time for eligible patients include … these same systems are needed when a patient develops a stroke during hospitalization
Unique issues include … primary stroke centers as a mechanism to standardize and centralize stroke care in the US
Basic elements include
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - 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
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - 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
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Updates include increased use by other organizations, slight modifications to the description of the … innovative activity, additional results that include Medicare and Medicaid expenditures and additional … Using evidence-based practices, key services include an initial assessment by the SASH staff team, creation … Key elements of the program include the following:
Enrollment and initial interview: As part of … Factors to consider include not only the size of the population, but also their level of physical and
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - 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
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Interventions
include patient-specific exercises that increase flexibility, teach new movement strategies … The
resulting plan of care may include exercises that foster beneficial physical adaptations through … These
benefits include fewer short- and long-term complications, and reduced length of stay. … In addition, the commentary does not include information
regarding investigational or off-label use … When patients can follow simple commands, interventions can include active-assisted and active
range
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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - of universal precautions for HCWs to follow with all patients, regardless of HIV status.( 4 ) These include … aerosolized particles.( 1,5 ) Accordingly, CDC guidelines for controlling risk of VZV transmission include … single patient rooms and a 3 feet minimum distance between all patients; airborne precautions include … Risk factors may include travel history, sick contacts, occupation, and results from diagnostic testing … Key infection control program components include HCW immunization verification, periodic immunity testing
-
psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - 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 … The main adverse effects of thiazides include hyponatremia, hypokalemia, hypomagnesemia, and hypercalcemia … These measures include using low starting doses and intensified monitoring around the time of treatment … In addition, the commentary does not include information regarding investigational or off-label use of
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - Persons at risk often include the elderly, those who have a history of substance abuse, or those with … Additional structured assessment tools that can be used include the Aid to Capacity Evaluation (ACE … System barriers that must be overcome to appropriately address the question of mental capacity include … For example, teams that do not include a social worker or mental health professional may not have the … A complete history must include a thorough psychosocial history to identify any potential psychological
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - and Risk Factors of Tracheostomy (2)
The benefits of tracheostomy, compared with endotracheal tubes, include … obesity, short necks, tracheal deviation, or
impaired neck extension
Indications for tracheostomy include … progressive dilation of the trachea at the cuff site.9,10
• The description of this case does not include … broader
hospital standards.13,14
• Tracheostomy teams can be structured in different ways and often include … • Policy and staff education should include airway cuff pressure monitoring
technique and protocols
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psnet.ahrq.gov/node/72618/psn-pdf
December 23, 2020 - Nudges may also include making the advantages of particular choices more apparent through how
the information … 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 decrease