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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - The family was advised to provide supportive care and counseled that it can take months to recover fully … Over the next several months the patient’s symptoms continued. … Yet the diagnosis was delayed for several months due to classic errors in the diagnostic process ; … Adrenal insufficiency often presents as a slow, progressive illness over many months. … Outpatient referral to a pediatric subspecialist often takes weeks or months and is not an appropriate
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psnet.ahrq.gov/
March 25, 2025 - Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
Date Created: March 21, 2024
Last … Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
Date Created: October 10, 2022
Last … Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
Date Created: March 8, 2023
Last … Kendall Hall, AHRQ PSNet Team
Date Created: October 23, 2023
Last Updated: March
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - opioid requirements
ranged from 120 to 300 OME.
6
Case Details (Encounter 1)
• After a several-months-long … long-
acting opioid prescription was for morphine sulfate ER 90 mg three
times daily (7-day supply) 2 months … Last updated June 2015. Accessed July 6, 2021.
7. The Joint Comission. … Last updated December 2009. Accessed July 25, 2021. … Last updated April 24, 2019. Accessed
July 25, 2021.
19.
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psnet.ahrq.gov/node/33660/psn-pdf
December 01, 2007 - for 1 month post-hospital, the patients were significantly more likely to stay out of the hospital 6
months … In other words, 5 months after the coach had disengaged with the patient, these patients
were still … patient gets home, the coach and patient would arrange for a home visit,
and this would typically last
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psnet.ahrq.gov/issue/increased-risk-burnout-physicians-and-nurses-involved-patient-safety-incident
September 21, 2016 - physicians and nurses in Belgium examined the relationship between involvement in an error in the past 6 months
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - rheumatologist returned from her conference the following week, the covering physician
gave her the patient's last … The rheumatologist happened to have two patients with the same last name,
and both had GCA. … A few months later, the correct patient underwent repeat lab testing, and his CRP was elevated once again … rheumatologist quickly called the patient for a follow-up appointment and realized that the elevated
CRP from 2 months
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psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - could return to his active lifestyle, but the elective procedure couldn't be scheduled for a couple of months … If he lives in the United States, it is unlikely that he would be subjected to a wait of several months … looks problematic due to the possibility of infection or excessive swelling, the patient may be facing months … This last issue raises concerns regarding liability exposure, since a patient with an adverse outcome … The US health care system recognizes this with global surgical fees that include up to 4 months of postoperative
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psnet.ahrq.gov/node/44834/psn-pdf
January 27, 2016 - Sustaining reliability on accountability measures at the
Johns Hopkins Hospital.
January 27, 2016
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue/sustain…
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psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - The family was advised to provide supportive care and
counseled that it can take months to recover fully … Over the next several months the patient’s symptoms continued. … kind of diagnostic delay remains common, with 40-50% of
patients experiencing symptoms for over 6 months … Adrenal insufficiency often presents as a slow, progressive illness over many months. … Outpatient referral to a pediatric subspecialist often takes weeks or months and is not an
appropriate
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psnet.ahrq.gov/node/42653/psn-pdf
January 07, 2015 - https://psnet.ahrq.gov/issue/safety-issues-related-electronic-medical-record-emr-synthesis-literature-last-decade
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - In one system, never
events occurred once every 38 months when more than 60% of surgical suite personnel … perceived safety
as good or excellent, versus once every 12 months in surgical areas with scores below … by educating
clinicians about how teamwork can effectively counteract these stressors.(12,13)
The last
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - The maturity in the field over the
last 10 years is that these are now explicit goals, and it's widely … It took us more than 6 months, a group of us that were doing this
while we were trying to do our main … seven words: goals, partnerships, alignment, culture,
leadership, flexibility, bidirectionality—that last … Many months were spent before this was launched developing the AHRQ National Scorecard
and the ability … (30% of Medicare payments tied to alternative payment
models) was actually hit in January 2016—11 months
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - If I, as CEO, can look them in the eye and say, the board is expecting us to
come back in 3 months with … asked this question, because it's something I think is one of the real important
learnings in the last … So you end up getting data that's 2, 3, 5,
7, even 9 months old when you do the "compared to whom" measurements … A few months later, when the medical staff executive
committee adopted a policy of full barrier precautions … In
the last year or two, we've seen three fairly large studies of boards and how they work and how they
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - In the last 10 years, overdose deaths have more than doubled in the United States. 5 As one response … an active opioid prescription or who have been treated for an opioid use disorder diagnosis in the last … STORM is one of many national opioid safety initiatives implemented in the last 5 to 10 years. … At 9 months, a randomly selected half of facilities expanded the case review mandate to cover patients … At 15 months, the other half of facilities expanded the case review mandate to cover patients in the
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - How do you think that has changed over the last 5 or 6 years? Dr. J. … It's so easy to come in early, stay late, skip the meal, finish that e-mail, see that last patient, squeeze … It's been reframed in the most recent versions that just came out in the past 9 months of TeamSTEPPS. … RW : If you asked people what the largest victory in the last 10 years in the safety field was, people … I haven't seen my kids in months. I'm now going through a divorce.
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - Innovator
Last … In comparing the 12 months before the GRACE intervention and the 25 months after the intervention, GRACE … in the median number of ED visits (5.5 to 0, p = 0.015) and hospitalizations (5.5 to 0, p<0.001) 6 months … after enrollment compared to 6 months before enrollment. … ago increased from 36% at enrollment to 64% at 9 months (p = 0.002).
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - How do you think that has changed over
the last 5 or 6 years?
Dr. J. … It's so easy to come in early, stay late, skip the meal, finish that e-mail, see that last
patient, … It's been reframed in the most recent versions that just came out in the past 9 months of
TeamSTEPPS … RW: If you asked people what the largest victory in the last 10 years in the safety field was, people … I haven't seen my kids in months. I'm now going through a divorce.
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Eight months later, he was admitted to the hospital with shaking chills and confusion and found to have … eight clinic visits with multiple physicians, and had no symptoms until his dramatic presentation many months … In the case above, an RSI went undetected for 8 months. … Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. … Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months
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psnet.ahrq.gov/node/849598/psn-pdf
May 31, 2023 - #8
https://psnet.ahrq.gov//#9
https://www.sccm.org/SurvivingSepsisCampaign/Home
For the first few months … Results
In the last 12 months of a 28-month study following implementation, the median monthly mortality
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psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - We have analyzed all data for the last 15 years, and our major and minor
complication rate for all of … that goes into making sure that once the line is placed, the line is well cared for so that it can
last … we have
found that, certainly what my experience personally was, it takes somewhere between 3 to 6 months