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81. 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

82. 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

83. All in the History | PSNet
    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

84. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/35633/psn-pdf
    January 16, 2024 - government organization supports patient safety efforts in Manitoba by supporting activities that include

85. 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

86. Medication/Drug Errors | PSNet
    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

87. Psn-Pdf (pdf file)
    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

88. Transfusion Thresholds in Gastrointestinal Bleeding | PSNet
    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

89. Coming Undone: Failure of Closure Device | PSNet
    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

90. Spotlight (pdf file)
    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

91. Psn-Pdf (pdf file)
    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

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50767/psn-pdf
    August 12, 2024 - Topic tracks for the session include workforce and patient safety, leadership and equity.

93. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72760/psn-pdf
    September 30, 2024 - Topics covered include electronic health records documentation, patient partnership and rural health

94. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet
    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

95. Diuretics and Electrolyte Abnormalities | PSNet
    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

96. Outbreak | PSNet
    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

97. A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors. | PSNet
    psnet.ahrq.gov/issue/multiobserver-study-effects-including-point-care-patient-photographs-portable-radiography
    March 04, 2015 - March 4, 2015 Improvement in detection of wrong-patient errors when radiologists include … June 1, 2019 Improvement in detection of wrong-patient errors when radiologists include

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866569/psn-pdf
    September 01, 2024 - Topics covered include medication safety, safe patient handling and safe surgical attire. 

99. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
    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

100. Psn-Pdf (pdf file)
     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