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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - identify at-risk patients and there is emerging evidence that supports multidisciplinary interventions including … dedicated pharmacists perform medication reconciliation at critical points during hospitalization, including … A return-on-investment calculator can be downloaded from the Society of Hospital Medicine website including … involving 18 medical centers that demonstrated mentored implementation of a refined best practices toolkit, including … The emphasis in MARQUIS2 was placed on interventions shown to reduce harmful discrepancies, including
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - At each ED visit, routine laboratory tests, including a complete blood count, liver function tests, urinalysis … nonocclusive ischemia can result from hypovolemia, poor cardiac function, and vasoconstrictive medications including … bowel ischemia has developed, one would expect worsening markers of infection and end-organ perfusion, including … It is also important to consider a pelvic etiology in female patients including genitourinary and gynecologic … sources of diagnostic error. 17 This physician overconfidence stems from complex interrelated factors, including
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - health care settings and providers, involves bridging care gaps across different health care settings, including … have been employed to avoid preventable adverse events after discharge and prevent rehospitalizations, including … penalties aside, readmissions can be quite costly, and they carry the potential for harm to the patient, including … Most of the successful transitional care programs, including the Transitional Care Model ( 6 ), the Care … Many of the interventions focus on certain diagnoses or localized groups of patients, including patients
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - The cardiac surgeon discussed the problem with the patient and his wife, including the numerous risks … He confirmed that she understood what happened, including the miscommunication among operating room team … It involves five components including: Identify the unexpected harm event. … Activate the system including the team leads trained in response and disclosure. … The AHRQ CANDOR Toolkit has helpful information for staff and family members, including a video demonstrating
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psnet.ahrq.gov/node/73365/psn-pdf
June 09, 2021 - Specific interventions are discussed, including family
involvement, leadership communication, and simulation
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - However, control of the source of sepsis is critical, and the physicians—including the surgeon who performed … Systematic pressures in modern inpatient care may detract from using iterative hypothesis testing, including … Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in
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psnet.ahrq.gov/node/838078/psn-pdf
September 14, 2022 - The authors suggest that future research explore
methods to mitigate EHR overload-related errors, including
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psnet.ahrq.gov/node/836969/psn-pdf
April 20, 2022 - highlights the negative impacts the recent criminal
conviction of a nurse could have for patient safety, including
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psnet.ahrq.gov/node/47615/psn-pdf
January 30, 2019 - report provides an overview of the
burnout crisis and recommends strategies to address the problem, including
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - this case, participants should be able to:
Identify characteristics of “high-risk” abdominal pain, including … comport with the history, physical examination, and any abnormal labs, and
consider additional testing—including … “High-risk” abdominal pain is
characterized by clinical features including age greater than 65 years … Although there were several red flags that were ignored or minimized in this case, including the history … marker for tissue hypoperfusion and a reliable test for early diagnosis of
abdominal catastrophe, including
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - that could be taken at an institutional level to address the staffing crisis and its implications, including … It also impacts people of color who are delivering care, including nurses. … Many patient outcomes and safety outcomes appear to be connected to nursing levels, including length … A range of variables, including the relative experience level of nursing staff, pre-existing staffing … from the American Association of Critical-Care Nurses (AACN) and American Nurses Association (ANA). 6 Including
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - From the mid-1990s through 2009, cesarean delivery rates rose by more than 50%, including increases for … Cesarean deliveries are thought to contribute to poorer birth outcomes for Black/African American women, including … operate a large-scale initiative in support of vaginal birth include: Input from multiple stakeholders, including … operate a large-scale initiative in support of vaginal birth include: Input from multiple stakeholders, including … , midwifery, and family medicine organizations, multiple purchasers and organizations, health plans including
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psnet.ahrq.gov/node/837415/psn-pdf
June 15, 2022 - The authors suggest future research should
consider including ethics in patient safety and responsiveness
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Root cause analysis of the case revealed several crucial missed steps in preparing for this procedure, including … pregnancy-related deaths at nearly four times the rate of white women.( 2 ) Several organizations, including … above demonstrates several opportunities to impact care and potentially prevent obstetric hemorrhage, including … filtration techniques.( 10 ) The PAS guidelines regarding other potential preoperative interventions (including
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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - in quality of care in HF, components of these guidelines have been adapted by various organizations, including … about HF but also nurse participation in the medical management of the patients as well as home visits, including … improvement project looking at the change in recognized performance measures over time for several diseases, including … Hospital teams should make every effort to improve the delivery of high-quality HF care, including complete
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psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
August 30, 2023 - brief discusses what has changed since the Keeping Patients Safe report was released a decade ago, including … in this special issue explore strategies to establish a culture of safety in health care settings, including … in this special issue explore strategies to establish a culture of safety in health care settings, including … Articles in this special issue highlight organizational elements that contribute to patient safety, including
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psnet.ahrq.gov/node/836712/psn-pdf
March 09, 2022 - Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including
broad
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psnet.ahrq.gov/node/61109/psn-pdf
November 11, 2020 - editorial discusses strategies for successful
implementation of CRPs highlighted in prior research, including
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - this case, participants should be able to: Identify characteristics of “high-risk” abdominal pain, including … comport with the history, physical examination, and any abnormal labs, and consider additional testing—including … “High-risk” abdominal pain is characterized by clinical features including age greater than 65 years, … Although there were several red flags that were ignored or minimized in this case, including the history … a marker for tissue hypoperfusion and a reliable test for early diagnosis of abdominal catastrophe, including
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - Scientists are now delineating the impact of psychological harm in
diverse settings, including in recent … brochures, posters, and video to encourage
engagement using best principles of health communication, including … Electronic health records (EHRs) have offered patients unprecedented access to their health information,
including