-
psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - oximetry or capnography)
• The Joint Commission has made specific recommendations
about policies and procedures … opioid-induced respiratory
depression, 50% had OSA
Identifying and Assessing High-Risk Patients (3) 17
• Methods
-
psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - surgical team placed an anesthetized patient onto a modular table during preparations for a spinal procedure … Human Factors Methods for Design: Making Systems Human-Centered. Boca Raton, FL: CRC Press; 2004. … Scott Snook calls "practical drift"—that is that organizations can start to deviate from established procedures … In some cases, the patients themselves might be interested in procedures or medications that might increase
-
psnet.ahrq.gov/periodic-issue/periodic-issue-404
August 30, 2023 - interprofessional education (IPE) does or does not improve students' attitudes towards patient safety, the methods … deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure
-
psnet.ahrq.gov/periodic-issue/periodic-issue-422
January 04, 2024 - Review
Methods for studying medication safety following electronic health record … No fracture or foreign body was identified on x-ray but the procedure note did not mention whether the
-
psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - goiter, Graves’ disease, and chronic
lymphocytic thyroiditis; and
3) Process-of-care factors such as procedure … – Such training includes regular review of airway algorithms, methods for airway
support and ventilation
-
psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - bleeding from a loosened uterine artery suture, an unrecognized laceration that occurred during the procedure … postdelivery, as occurred in this patient.( 12 ) Furthermore, the operative field may appear dry during the procedure … June 30, 2011
Exploration of a rapid response team model of care: a descriptive dual methods
-
psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - Research has found that active learning methods (e.g., simulations , discussions) are more effective … for retaining information and supporting attitude and behavioral changes than passive learning methods
-
psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - Research has found that active learning methods (e.g., simulations , discussions) are more effective … for retaining information and supporting attitude and behavioral changes than passive learning methods
-
psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - been historically underappreciated for many reasons – the data are limited, there
are few reliable methods … The most common system-related problems were due to
poor policies, processes, procedures, teamwork,
-
psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - health resource utilization impacts of prefilled syringes versus conventional medication administration methods … When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures
-
psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - Many of these errors are caught before harm reaches the patient, as practitioners have a variety of methods … diagnosis, updated medications and problem list, current baseline status (eg, cardiac status), and recent procedures
-
psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - the bone marrow leading to chronic anemia) underwent an uncomplicated coronary artery bypass grafting procedure … All of these methods were equally as effective in reducing either the amount of blood products transfused
-
psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - one-on-one exchange and can be haphazard if the person they're signing out to is in the middle of a procedure … 2020
Implementation and sustainability of a medication reconciliation toolkit: a mixed methods … January 11, 2017
Understanding patient-centred readmission factors: a multi-site, mixed-methods
-
psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - that really lowers my bar for saying I'm willing to live with the warts that come with risk adjustment methods … At this point, the goals we are trying to achieve are clearer than the best methods to reach them.
-
psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - employees in improvement, instead of just expecting them to come to work and follow a standard operating
procedure … RW: There's a long history of industrial improvement methods that have been used religiously for 3 or … where we eat better, and exercise all
the time instead of relying on a new pill or a new surgical procedure
-
psnet.ahrq.gov/issue/risk-propensity-and-safe-medication-administration
December 08, 2010 - Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods
-
psnet.ahrq.gov/issue/medication-administration-errors-and-pediatric-population-systematic-search-literature
September 16, 2015 - Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods
-
psnet.ahrq.gov/issue/future-engaging-patients-and-families-patient-safety
January 27, 2016 - January 31, 2024
Reconceptualizing patient safety beyond harm: insights from a mixed-methods
-
psnet.ahrq.gov/periodic-issue/periodic-issue-439
May 29, 2024 - Study
The Safe Home Care Intervention Study: implementation methods and effectiveness
-
psnet.ahrq.gov/node/33693/psn-pdf
February 01, 2010 - Participating EIP programs have
developed methods to conduct individual practice assessment in ambulatory