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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - Infections
June 15, 2024
Patient Safety Primers
Long-term
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psnet.ahrq.gov/node/33577/psn-pdf
September 15, 2024 - Background
Long and unpredictable work hours have been a staple of medical training for centuries. … In fact, the term
"resident" is a relic of times when physicians in postgraduate training literally
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - Consider impact of disclosure vs. non-disclosure
Error disclosure must be accompanied by offers of long … term support, remedial treatment, and continuing relationship with patient and family
Disclosure
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psnet.ahrq.gov/node/854973/psn-pdf
October 31, 2023 - Association between health literacy, eHealth literacy, and health outcomes
among patients with long-term
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - delivery, brachial plexus injury (transient and permanent), and hypoxic ischemic encephalopathy at term … those resulting in birth trauma—are emotionally and financially devastating to families and result in long-term … (no permanent injury for > five years ), halved the incidence of hypoxic ischemic encephalopathy at term … years despite an unchanged rate of shoulder dystocia, the rate of hypoxic ischemic encephalopathy in term … less than 7 per 10,000 deliveries) and the annual proportion of umbilical artery pH of < 7.00 among term
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long … Short- versus long-term dual antiplatelet therapy after drug-eluting stent implantation: an individual
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - He expired not long after from a perforated bowel. … In long-term care, only 22% of new RN graduates had a comprehensive transition
https://psnet.ahrq.gov
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psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - Moreover, an analysis of new prescriptions of long-acting opioids for chronic noncancer pain showed … These mixed results suggest that larger, longer-term studies are needed to assess the effect of state-level … Importantly, the new guideline favors immediate-release medications rather than long-acting formulations
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital … Also, the antimicrobial resistance agenda has been there for a long time.
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - The term of art in this arena is called harmonization. … That program has grown and flourished, and it was a long battle to get the right mix of clinically valid … organizations and programs that we accredit or certify topped out last year at about 16,000 including long-term
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - I, like many people, had an abstract mental model in my head that so long as people did their jobs and … There's a long history of people entering health care and saying it's probably just like GE or Alcoa … Those engagements are longer term encounters, compared with most patient-care encounters. … That created long queues and the company had to figure out how to re-standardize some elements of it. … Ergo, their care was complicated and long lived.
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - I, like many people, had an abstract mental model in my head that so long as people did their jobs and … There's a long history of people entering health care and saying it's probably just like GE or Alcoa … Those engagements are longer term encounters, compared with most patient-care encounters. … That created long queues and the company had to figure out how to re-standardize some elements of it. … Ergo, their care was complicated and long lived.
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psnet.ahrq.gov/web-mm/xl-or-smaller
September 13, 2017 - Although the practice of using a similar trade name for long- and short-acting preparations saves the … Long-term experience with a program to improve prescription-writing skills.
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - appropriately during the intrapartum period.( 1,2 ) For neonates who survive early-onset GBS disease, long-term … September 1, 2008
WebM&M Cases
Waiting Too Long
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - However, no long-term harm occurred. … Due to the relatively long and variable time to achieve steady state, phenytoin loading doses are commonly
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psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - Lastly, once the urgency of the situation has resolved, replacing the IO needle with more long-term IV … either too deep [through back wall of bone in infants] or too shallow [attempted use of insufficiently long
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - influenced preoperative management ranged from 0%-3%
Normal test result within 4 months can be used, as long … Prothrombin time (PT) History of bleeding diathesis, chronic liver disease, malnutrition, recent or long … term antibiotic use
Partial thromboplastin time (PTT) History of bleeding diathesis
Electrolytes Known
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - Luckily, however, there were no long-term adverse sequelae.
What went wrong in this case? … At times, this line of reasoning
may be correct—in many institutions, the wait can be long enough to
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - We are hopeful that each of the parties involved in diagnosis—and it's a long list of stakeholders that … the habit of knowing how well calibrated we were, we might end up better-calibrated physicians in the long … The second is the oral exam, which I think is still done in the UK but is long gone in medicine in the … But looking at IOM reports, they are already very long. This report is 300 or 400 pages.
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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - For his diabetes, at home he was on a complex regimen of twice daily insulin glargine (Lantus, a long-acting … insulin), insulin NPH (another long-acting insulin) once in the morning, and regular (short-acting) … setting.( 3-5 ) Although this patient presented to the hospital with a complex home regimen of two long-acting … This target could likely be achieved using a long-acting insulin (such as glargine or levemir) for basal … To solve the problem in the short term, a paper tracking system of insulin dosing, blood sugars, and