-
psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - characteristics of medication options and letting doctors select the best and most affordable drugs, including … Health IT, including e-prescribing, creates opportunities to improve patient safety that do not exist … While evidence suggests that implementing new technology (including e-prescribing) improves patient safety … To maximize the benefits of e-prescribing, including improved transmission and reduced medication errors … A function that requires the prescriber to review all prescriptions (including new, renewals, or changes
-
psnet.ahrq.gov/curated-library/value-and-patient-safety
October 30, 2019 - on a workshop that explored methods to engage patients and families in safety improvement efforts, including … As such, the author asserts that future safety research, including patient safety, must begin by clearly … This systematic review including 67 studies identified several cost-effective interventions addressing … health care-associated infections, including screening high-risk individuals, universal decolonization … The Nudge Unit at Penn Medicine focuses on a range of different care improvement projects, including
-
psnet.ahrq.gov/node/33595/psn-pdf
December 15, 2024 - Sleep deprivation has long been known to impair various cognitive functions, including mood,
motivation … Studies—including research
supported by AHRQ—have shown that residents make fewer errors in the setting … handoff practices; involving staff in design of work
schedules; implementing a fatigue management plan including
-
psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - survive sepsis face residual health problems and reduced life expectancy. 5
Sepsis has multiple causes, including … the EHR to assure the clinical team’s responsiveness and implementation of specific bundle elements, including … Data elements and measures should focus on bundle compliance including implementing the bundle and response … to the innovation team, to sustain the innovation requires the following:
Adoption by all staff including
-
psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - PSNet highlights the latest patient safety literature, news, and expert commentary, including … 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 … PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
-
psnet.ahrq.gov/clinical-areas
March 24, 2025 - piece discusses the role that healthcare providers and organizations can play in suicide prevention, including … piece discusses the role that healthcare providers and organizations can play in suicide prevention, including … Survey respondents also endorsed the importance of formal support programs, including peer support, education … This article highlights the effect that unprofessional behavior, including more subtle forms such as
-
psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - 30%, mirroring national trends. 3 The VTE Collaborative approached the problem from several angles, including … resources and skills: A multidisciplinary team Time for members to participate in the collaborative, including … research, development, implementation, and sustaining of the intervention(s) Institution-wide buy-in, including … resources and skills: A multidisciplinary team Time for members to participate in the collaborative, including … research, development, implementation, and sustaining of the intervention(s) Institution-wide buy-in, including
-
psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - We filmed 15 families, including Spanish-speaking families, and observed hundreds of hours of their journeys … You need to know what's confidential and how information might be used, including if it can be used against … KT: We have been doing that, including taking pictures, making detailed notes on conversations we have … We have a lot of coping strategies including medication and also hot pads and baths and ice packs, etc … These measures primarily include assessment of maternal mortality and morbidity, including outcomes such
-
psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - These measures primarily include assessment of maternal mortality and morbidity, including outcomes such … importance of safety as a positive concept and the impact that structural and social determinants, including … root causes of disparities in maternal safety has become an increasing priority in the United States, including … KT: We have been doing that, including taking pictures, making detailed notes on conversations we have … We have a lot of coping strategies including medication and also hot pads and baths and ice packs, etc
-
psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - typically geared toward identifying and responding to signs of distress through a number of means, including … These signs would alert any member of the treatment team (including ancillary staff, such as the transport … Of course, training for all staff (including nonclinical personnel) regarding what “Continuous Observation … Visitors should be supervised to ensure no transfer of potentially lethal means including prescriptions
-
psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - There are three major components of the system including: The robot, which is a mobile tower with four … arms, including a camera arm and three instrument arms. … Risks of Robotic-assisted Surgery RAS shares the same risks of open and laparoscopic surgery, including … Multiple components of the system can malfunction, including the camera, binocular lenses, robotic tower … RALP has reported complication rates (including all grades of perioperative complications, from minor
-
psnet.ahrq.gov/primer/falls
October 27, 2021 - More than one-third of in-hospital falls result in injury, including serious injuries such as fractures … Continence management, including routines of offering frequent assistance to use the toilet. … A postfall review used as an opportunity to plan secondary prevention, including a careful history to
-
psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - She was managed supportively – as is the evidence-based approach – for acute idiopathic pancreatitis, including … Upon readmission, her neurological status, including profound weakness and encephalopathy, had continued … much of this updated problem representation is the same, new information has been added to the frame, including … Fortunately, the modern environment also has enabling factors for teamwork, including an electronic health … record to which all team members – including patients and their families – can contribute and view one
-
psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - Citation
Annual Perspective 2016
Opioid medications confer significant risks of harm, including … Some communities, including Baltimore , are promoting the distribution of naloxone in an effort to prevent … Healthcare Research and Quality has several efforts underway to broaden the evidence base for opioid safety, including … disabled Medicare beneficiaries did not find reductions in high-risk opioid prescribing practices (including … This year also saw the emergence of some promising approaches to enhancing opioid safety, including widespread
-
psnet.ahrq.gov/about-psnet
September 01, 2015 - AHRQ PSNet also hosts all previous AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) content, including … These resources come in a variety of formats, including literature, research, tools, and Web sites. … They come from a wide range of disciplines and sources, including clinical medicine, health care administration
-
psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - Residents taking medications in several drug categories—including antipsychotic
https://psnet.ahrq.gov … prescribing and monitoring errors stem directly from inadequate
information at the time of ordering, including … occurrence of adverse drug events in nursing home
residents.(13) Structured communication strategies, including … , and other health professionals, has the potential to improve quality of care across many
domains including
-
psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - In cases of definite tendon disruption, specialty follow-up ensures timely management, including operative … The authors attributed misdiagnosis primarily to a lack of knowledge, lack of experience (including examination … hand injuries in Northern Ireland referred to a plastic surgery unit, the initial treating clinicians—including … These authors noted several opportunities to reduce the incidence of missed tendon injuries including … A thorough hand examination, including neurovascular and functional testing, is required for all hand
-
psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Sleep deprivation has long been known to impair various cognitive functions, including mood, motivation … Studies—including research supported by AHRQ—have shown that residents make fewer errors in the setting … handoff practices; involving staff in design of work schedules; implementing a fatigue management plan including
-
psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - There were no changes made to any of the medications he was taking before the hospitalization, including … United States alone.( 1 ) When taken correctly, it effectively reduces the risk of thromboembolism, including … period.( 5 ) Warfarin is responsible for 8% of all adverse drug events following hospital discharge, including … on chronic warfarin, patients newly started on warfarin are at a much higher risk of complications, including … For many patients, however, including the patient in this case, the new anticoagulants will present attractive
-
psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - AHRQ in 2008, was retired in March 2021; AHRQ now offers select content from the Innovations Exchange, including … professionals who have experience and competence in helping patients advocate and care for themselves, including … execute the postdischarge self-care plan and participate in their own care coordination activities, including … During this time, the Transitions Coach focuses on providing continuity of care across settings, including … professionals who have experience and competence in helping patients advocate and care for themselves, including