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21. Fatigue among clinicians and the safety of patients. | PSNet
    psnet.ahrq.gov/issue/fatigue-among-clinicians-and-safety-patients
    November 15, 2018 - The authors discuss the likely consequences of these limitations, including decreased work force, increased … Specific challenges, including behavioral and cultural shifts as well as potential economic impact, are

22. Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. | PSNet
    psnet.ahrq.gov/issue/prevalence-and-characterisation-diagnostic-error-among-7-day-all-cause-hospital-medicine
    April 12, 2023 - These diagnostic errors were primarily related to clinician diagnostic reasoning , including failure … The majority of the diagnostic errors resulted in some form of clinical impact, including short-term

23. Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review. | PSNet
    psnet.ahrq.gov/issue/economic-evaluations-interventions-prevent-and-control-health-care-associated-infections
    May 18, 2022 - This systematic review including 67 studies identified several cost-effective interventions addressing … health care-associated infections, including screening high-risk individuals, universal decolonization

24. Safe practice environment chapter proposed by USP. | PSNet
    psnet.ahrq.gov/issue/safe-practice-environment-chapter-proposed-usp
    May 02, 2018 - This article discusses work space factors that can affect safe medication delivery, including lighting … June 10, 2018 Benefits and risks of including patients on RCA teams.

25. Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed? | PSNet
    psnet.ahrq.gov/issue/ten-years-after-keeping-patients-safe-have-nurses-work-environments-been-transformed
    April 04, 2018 - brief discusses what has changed since the Keeping Patients Safe report was released a decade ago, including … Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including

26. Systemic failures in nursing home care--a scoping study. | PSNet
    psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study
    July 17, 2013 - This scoping review including 38 articles identified 29 systemic issues faced by nursing homes, including

27. Changing the "working while sick" culture. | PSNet
    psnet.ahrq.gov/issue/changing-working-while-sick-culture
    March 14, 2018 - Clinicians often feel pressured to work while sick or fatigued because of cultural and system factors, including … The authors recommend strategies and policies to address this problem, including promoting professionalism

28. Information transfer and communication in surgery: a systematic review. | PSNet
    psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
    September 26, 2012 - systematic review of 38 published studies identified communication failures in all phases of surgical care, including … A number of interventions have been proposed to address this issue, including standardized checklists

29. Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review. | PSNet
    psnet.ahrq.gov/issue/comparative-economic-analyses-patient-safety-improvement-strategies-acute-care-systematic
    November 07, 2012 - systematic review evaluated the cost-effectiveness of interventions to address 15 key safety targets (including … Based on this limited dataset, the authors identified 4 cost-effective safety interventions, including

30. Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association. | PSNet
    psnet.ahrq.gov/issue/medication-errors-acute-cardiovascular-and-stroke-patients-scientific-statement-american
    February 03, 2011 - from the American Heart Association reviews the specific types of medication errors in these patients, including … specific, evidence-based recommendations for preventing medication errors in this patient population, including

31. Safety at the time of the COVID-19 pandemic: how to keep our oncology patients and healthcare workers safe. | PSNet
    psnet.ahrq.gov/issue/safety-time-covid-19-pandemic-how-keep-our-oncology-patients-and-healthcare-workers-safe
    September 03, 2011 - The authors recommend several approaches ensure patient safety, including COVID-19 prescreening/screening … They also propose measures focused on healthcare worker safety, including appropriate use of personal

32. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. | PSNet
    psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
    December 02, 2014 - The team utilized a number of overlapping interventions, including proactive risk identification, frequent … 12, 2016 Successful implementation of standardized multidisciplinary bedside rounds, including

33. 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 - The Nudge Unit at Penn Medicine focuses on a range of different care improvement projects, including … This approach can be applied to a wide variety of quality improvement projects, including those with … organizations have engaged Penn Medicine with interest in establishing their own nudge/behavioral health units, including … Assess different types of existing data from various sources, including patient behaviors and characteristics

34. Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events. | PSNet
    psnet.ahrq.gov/issue/two-state-collaborative-study-multifaceted-intervention-decrease-ventilator-associated-events
    January 15, 2014 - Patients requiring intensive care are particularly vulnerable to preventable adverse events, including … Participating hospitals were able to significantly reduce the rate of ventilator-associated adverse events (including

35. Protocol-based computer reminders, the quality of care and the non-perfectability of man. | PSNet
    psnet.ahrq.gov/issue/protocol-based-computer-reminders-quality-care-and-non-perfectability-man
    April 24, 2018 - computerized decision support systems improve physician performance at a variety of processes of care, including … January 23, 2017 Impact of including readmissions for qualifying events in the Patient

36. A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program. | PSNet
    psnet.ahrq.gov/issue/checklist-based-intervention-improve-surgical-outcomes-michigan-evaluation-keystone-surgery
    May 01, 2015 - Surgery hospitals to those that did not implement the intervention found no differences in outcomes (including … April 6, 2022 A retrospective audit of postoperative days alive and out of hospital, including

37. Methods for studying medication safety following electronic health record implementation in acute care: a scoping review. | PSNet
    psnet.ahrq.gov/issue/methods-studying-medication-safety-following-electronic-health-record-implementation-acute
    February 03, 2011 - This scoping review including 27 articles found wide variation in how medication safety is evaluated … propose a sociotechnical-based conceptual model to evaluate medication safety in future studies, including

38. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
    psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - Grossly contaminated wounds require meticulous attention, including debridement of devitalized tissue … But even seemingly minor wounds may harbor foreign matter that may lead to a future complication, including … Before exploring an extremity wound, clinicians should perform a thorough neurovascular assessment including … For some patients, probably including the one in this case, even delayed closure is not feasible or may … First, a standardized approach to wound exploration and management, including wounds near or over a joint

39. Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans | PSNet
    psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
    July 23, 2024 - Access to Fall TIPS resources Fall TIPS training and retraining for nursing and non-nursing staff, including … Patients are particularly vulnerable to falling while in the hospital due to a number of factors, including … six most common reasons patients in hospitals fall: the patient fall history, high-risk conditions (including … Including the input of people who know the patient best allows for greater customization. … Outreach and education on the program should reach various hospital groups, including the Quality and

40. A Fatal Twist in Pseudohyperkalemia | PSNet
    psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
    February 10, 2021 - , and abnormal automaticity. 5 These mechanisms provide the substrate for ventricular arrhythmias, including … report of hyperkalemia, the patient presented with several signs suggesting the opposite – hypokalemia − including … Points Failure to recognize lab values affected by hemolysis can lead to serious patient outcomes, including … themselves with the ECG manifestations of and treatment options for severe electrolyte abnormalities, including … Clinical data, including machine ECG interpretations and automated laboratory results, should be independently