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201. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45831/psn-pdf
     January 25, 2017 - and-medications Opioid medications are associated with an increased risk of adverse drug events, including … Researchers found that those with underlying psychiatric and behavioral conditions (including opioid

202. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38428/psn-pdf
     February 18, 2009 - outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including … no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including

203. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865656/psn-pdf
     April 24, 2024 - occur in the midst of high-stress situations coupled with the bypassing of available layers of safety including … the provider is performing a sterile procedure.2 Verbal orders can result in error in several ways, including … should be included in verbal orders Guidance on clear and effective communication of verbal orders, including … However, similar scenarios are often loosely referred to as overrides, including removal of a medication … urine toxicology screening, blood alcohol level, metabolic panel including liver-associated enzymes

204. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865374/psn-pdf
     March 27, 2024 - These factors, including disorganized data, overburdened clinicians, and complex clinical cases, create … Additionally, some healthcare payers, including CMS, have started covering specific AI-assisted diagnostic … Researchers and developers are attempting to mitigate the effects of bias in several different ways, including … (2) establishing robust quality assurance processes to continuously evaluate AI model performance (including … In the near future, clinicians could be assisted with many of their daily tasks, including risk prediction

205. Continuing Education | PSNet
     psnet.ahrq.gov/continuing-education
     February 26, 2025 - was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including … Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions … Copy URL A 38-year-old man sustained multiple injuries in a motorcycle crash, including … Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache … was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including

206. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-471
     December 31, 2024 - PSNet highlights the latest patient safety literature, news, and expert commentary, including … Making Healthcare Safer IV: Opioid Stewardship explores the use of prescribed and ordered opioids, including … This call for public comment seeks to understand the impacts of ageism on healthcare quality, including … Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions … PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly

207. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60609/psn-pdf
     June 24, 2020 - The Commentary  By Julia Munsch, PharmD and Amy Doroy, PhD, RN  Benzodiazepines, including lorazepam … however, this class of drugs is frequently associated with errors that can result in adverse events including … hospital at legal risk by failing to follow several of the 8 “rights” of medication administration including … Multiple complicating factors exist at night, including the well documented effect of sleep disturbance … #12 https://psnet.ahrq.gov//#12 https://psnet.ahrq.gov//#13 Reading the complete medication order, including

208. Surgical Site Infections | PSNet
     psnet.ahrq.gov/primer/surgical-site-infections
     December 15, 2024 - factors (such as age, tobacco use, diabetes, and malnutrition) and procedure-specific risk factors (including … This project aims to address multiple types of patient harm, including SSI and other harms, in an integrated … The Joint Commission includes use of guidelines to prevent health care-associated infections, including … 2010 and 2015 and remained stable through 2017 , translating into significant benefits for patients (including

209. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46135/psn-pdf
     July 11, 2017 - associated-events 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

210. Infection After Carpal Tunnel Surgery | PSNet
     psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
     May 28, 2014 - Szabo, MD, MPH, FAOA Background  Carpal tunnel syndrome is a constellation of signs and symptoms including … Intraoperative Measures Maintain strict aseptic techniques including surgeon and patient hand cleaning … Instruct the patient on proper wound care, including keeping the bandage and wound clean and dry. … Staff Training and Education : Provide ongoing education and training for healthcare providers including … Employ careful sterile practices including patient and surgeon hand cleansing and attend to meticulous

211. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33573/psn-pdf
     March 15, 2025 - Commission requires that organizations have an explicit code of conduct policy for all staff and recommends including … a systems-level approach to identifying, monitoring, and remediating poorly performing physicians, including … Current Context The Joint Commission's Leadership Standard went into effect in 2009, including mandates

212. Delayed Recognition of a Positive Blood Culture | PSNet
     psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
     January 29, 2020 - She received further workup including additional blood cultures and a lumbar puncture, which remained … with signs of infection such as fever and leukocytosis), providers might consider several strategies, including … Choosing Wisely recommendations.( 7 ) Conversely, inadequate treatment of true positive blood cultures, including … of care for reporting of positive blood cultures is under one hour.( 17 ) Reporting critical values, including … One could speculate causes for delay, including high clinical workload, competing demands, issues with

213. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! | PSNet
     psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
     February 01, 2023 - and the patient was discharged the next day with instructions to resume all his prior medications, including … class of medications has been shown to improve glycemic control with a favorable cardiorenal profile, including … However, these medications can have adverse events, including genitourinary infections and eDKA. 4,5 … the most appropriate and safe medication regimens. 14 This approach involves multiple stakeholders, including … Assess the patient's risk factors, including comorbidities and conditions that may affect medication

214. In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
     December 14, 2022 - CCSQ works collaboratively across all centers in CMS including Medicare, Medicaid, the Marketplace and … The programs cover almost all facilities, including post-acute care from skilled nursing facilities, … Many people look to our websites, including the Care Compare sites, which provide performance measure … There are many explanations for these increases — including COVID-19 itself. … This also allows the transition from primarily chart-abstracted or claims-based measures to including

215. Measuring Patient Safety | PSNet
     psnet.ahrq.gov/perspective/measuring-patient-safety
     December 14, 2022 - Prior work focused on patient safety measurement, including the transition to digital measures, will … CCSQ works collaboratively across all centers in CMS including Medicare, Medicaid, the Marketplace and … The programs cover almost all facilities, including post-acute care from skilled nursing facilities, … There are many explanations for these increases — including COVID-19 itself. … This also allows the transition from primarily chart-abstracted or claims-based measures to including

216. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet
     psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
     February 28, 2024 - inception, TeamSTEPPS training has been widely implemented across a variety of healthcare settings, including … AHRQ sought input from several sources to inform the updates, including a technical expert panel composed … With a need to engage every member of the health care team, including patients and caregivers, it became … Including the patient as a part of the team changes a lot within the curriculum. … The website has resources , including training slides, for people who teach TeamSTEPPS.

217. In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 | PSNet
     psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
     February 28, 2024 - Stephen Hines: I have been involved with TeamSTEPPS since the early 2000s, including the initial TeamSTEPPS … With a need to engage every member of the health care team, including patients and caregivers, it became … Including the patient as a part of the team changes a lot within the curriculum. … The website has resources , including training slides, for people who teach TeamSTEPPS. … There were challenges, including the amount of content to be revised and coordination of revisions across

218. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet
     psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
     September 30, 2020 - The emergent nature of the patient’s cesarean delivery increased her risk for complications including … Background Worldwide, including the United States, obstetric hemorrhage is the leading cause of severe … Furthermore, the Joint Commission recommends having stage-based management for postpartum hemorrhage, including … leading to earlier recognition of conditions that can contribute to maternal morbidity and mortality, including … Abnormal findings should trigger more thorough bedside evaluation, including history-taking and physical

219. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/857061/psn-pdf
     November 27, 2023 - In that capacity, I have served on numerous education initiatives, including the recent re-envisioning … Under this initiative, AACN offered 12 learning modules, including six focused on undergraduate education … The process included input from a wide variety of stakeholders, including input and engagement from … The competencies are relevant for any area of practice, including the patient safety-related and quality … It includes multiple resources, including learning and assessment strategies for programs.

220. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863308/psn-pdf
     February 28, 2024 - Surgical factors can also increase the risk of aspiration including head-down positioning and certain … Additional steps should be considered to confirm there are minimal contents in the stomach including … The emergency airway algorithm dictates that “alternative intubation approaches” be attempted, including … All attempts to secure an airway in an emergency must be made, including performing a surgical airway … Ventilate the patient who has aspirated with 100% oxygen, utilizing airway adjuncts including LMAs as