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1381. Telehealth and Patient Safety During the COVID-19 Response | PSNet
      psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
      May 14, 2020 - It is important for institutions to maintain good patient safety culture and ensure that providers have … Joel Willis: This is Joel Willis and I am a family medicine trained physician and I just completed residency … stroke telemedicine in much the same way they would from outside the hospital, but in this case from just … NS : Just last night we were recording a video showing how a clinician can walk a patient through an … I think you should have a quality assurance plan as well, just like we have M&M [morbidity & mortality

1382. Unseen Perils of Urinary Catheters | PSNet
      psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
      January 31, 2024 - Just prior to insertion of the catheter by a registered nurse (RN), the patient voided but the amount … Since the patient had just voided, the RN assumed the patient's bladder was empty. … focused competency-based approach to review the microbiology of CAUTI, urinalysis collection, and urine culture … As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily

1383. Inadvertent Use of More Potent Acid Leads to Burn | PSNet
      psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
      November 01, 2023 - The physical exam revealed a raised lesion on the perineum, midline, just outside of the introitus. … November 12, 2008 WebM&M Cases Culture Clash No More:

1384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49548/psn-pdf
      October 01, 2007 - Clues to the development of thyroid storm (beyond just thyrotoxicosis) could include tachycardia, atrial … When both infection and thyrotoxicosis are present, routine cultures and early initiation of broad-spectrum

1385. Dying in the Hospital With Advanced Dementia | PSNet
      psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
      November 01, 2016 - , and another study of 178 EMTs noted that POLST forms were often hard to locate when needed.( 15 ) Just … family had thought their doctor had been informed of their mother's death and assumed that the PCP was "just … Medicare coverage for advance care planning: just the first step. … March 31, 2022 WebM&M Cases Culture Clash No More

1386. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
      January 23, 2017 - Workplace culture and human resource availability are common barriers to best practices To understand … Numerous barriers to reporting exist including fear of consequences, a culture of blame, perception … errors in a user-friendly and non-punitive manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors … October 30, 2024 WebM&M Cases Premature Closure: Was It Just

1387. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73387/psn-pdf
      March 17, 2021 - modifications are necessary moving forward to continue to improve the safety of healthcare facilities, not just … Culture and Redesign. Agency for Healthcare Research and Quality; 2008.

1388. Shortcuts to Acetaminophen-induced Liver Failure | PSNet
      psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
      July 01, 2017 - Although limited data exist, the prevailing culture of medicine is toward nonintervention during pregnancy … and interventions in pregnancy is laudable, medical or surgical risks need to be balanced against not just … simulation training, morbidity and mortality reviews, critical thinking training, and an organizational culture

1389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49667/psn-pdf
      October 01, 2012 - to be helpful, the instinct of all clinicians has to change from one of "this is unusual, but I'll just … Subsequently, the environmental culture needs to support and encourage clinicians to report medication

1390. Medication Handling and Compounding Errors in the Operating Room. | PSNet
      psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
      May 16, 2022 - medication dispensing machine should be used, an example of confirmation bias (evidence that confirms a belief … studied to address this concern. 13-15 The usage of D5W as a solvent for ICG has been shown to be just … Rethinking surgical safety: more than just a checklist.

1391. Suicide Prevention | PSNet
      psnet.ahrq.gov/perspective/suicide-prevention
      March 24, 2025 - It used to be three days, and it was just recently increased to seven days. … This is important because it emphasizes the healthcare system's role in preventing suicide, not just … It is not just positive or negative, it is not just a binary outcome. … Screening is just the beginning. … Annual Perspective Ensuring Patient and Workforce Safety Culture

1392. In Conversation with Edwin Boudreaux about Suicide Prevention | PSNet
      psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
      March 25, 2025 - It used to be three days, and it was just recently increased to seven days. … This is important because it emphasizes the healthcare system's role in preventing suicide, not just … It is not just positive or negative, it is not just a binary outcome. … Screening is just the beginning. … Annual Perspective Ensuring Patient and Workforce Safety Culture

1393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60173/psn-pdf
      March 30, 2020 - The new cross-cutting topics, such as Safety Culture, Teamwork and Communication, etc. also help to … Just putting sepsis early detection systems in your EHR doesn’t necessarily save lives. … This is something that we are just starting to get our arms around, and we should spend more time on

1394. The Unfinished Patient Safety Agenda | PSNet
      psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
      August 01, 2005 - of the American Nurses Credentialing Center is the best example of a successful blueprint to guide culture … Is it that there's not enough money, or that the culture is not one that promotes recruiting and retaining … We just believe that the people who are best able to determine what each unit needs are those who are … Finally, we need a culture in which safety is considered a problem-solving situation and not a punishment

1395. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49663/psn-pdf
      September 01, 2012 - While most cases of phlebitis are noninfectious (just inflammation of the vein), this can progress to … Blood cultures drawn at the time grew methicillin-resistant Staphylococcus aureus (MRSA), most likely … phlebitis.( 1,2) In a prospective study of 3165 patients, however, the majority of phlebitis cases were culture-negative

1396. In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - We’ve seen setbacks in safety culture scores, engagement, and feeling valued, as well as  attrition from … It’s about ensuring that the work environment, cultures of safety and equity, safety systems, competencies … The first foundational area is culture, leadership, and governance—ensuring that there is a core value … support and reflect healthcare workers’ workflow, and the conditions in which they work, and people are just … and items related to workplace culture of safety .

1397. Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - many healthcare workers noted an overall downward shift in the results of surveys of patient safety culture … and items related to workplace culture of safety . … It’s about ensuring that the work environment, cultures of safety and equity, safety systems, competencies … The first foundational area is culture, leadership, and governance—ensuring that there is a core value … support and reflect healthcare workers’ workflow, and the conditions in which they work, and people are just

1398. Accreditation and Regulation: Can They Help Improve Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
      April 01, 2009 - It is not surprising, therefore, to find a certain tension between the culture of medicine and the demands … RW: Do you have any sympathy for the hospital that says, "We just can't afford to continue to do this … The challenge for hospitals is to develop ways to credential physicians that meet not just The Joint … If you think back just 10 years ago, when hospitals were not measuring anything on any sort of national

1399. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49828/psn-pdf
      May 01, 2018 - Although a variety of approaches might be effective depending on local practice culture and EHR capabilities … However, patients desire more than just access to test results—they also want to know their clinicians … Improving test result follow-up through electronic health records requires more than just an alert.

1400. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73300/psn-pdf
      July 01, 2022 - can tailor components to align with their organizational needs, priorities, available resources, and culture … root-cause-analysis https://psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name … https://psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name https