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psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
February 24, 2021 - A dense oral culture that celebrates the benefits to safety and quality care that teamwork provides ( … The system changes necessary for high quality and safe care are impossible unless we recognize and change … To Err is Human: Building A Safer Health Care System. … April 21, 2015
Perspective
Long-Term Care and the Response
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - example, in a briefing the surgeon might ask the
anesthesiologist if there are any particular patient care … Take-Home Points
All health care providers performing invasive procedures must adopt the Joint Commission … Each institution should decide how the Universal Protocol and time out are documented, but care
must
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - pathological fracture” and it was determined she needed pediatric
orthopedics specialty care. … • The patient continued to recover and was monitored appropriately in the
intensive care unit. … medications,
expressed in both mass and volume units, have been recommended for pediatric
critical care … Pediatr Crit Care Med.
2016;17(12):1109–1116. [Free full text]
References
52
18. … beliefs of healthcare professionals on the causes and reporting of medication errors in a UK intensive care
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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - The nursing home setting provides a very complex set of challenges to providing safe and high-quality care … Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient … The incidence of adverse drug events in two large academic long-term care facilities. … Others have sub-acute care, with very distinct dynamics and types of staff that work in them. … Health Care Providers
Health Care Executives and Administrators
Geriatrics
Medication Safety
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - KH: I like this idea of the architecture being an adjunct to providing the care. … AJ: In the hospital, I think the other areas that are hugely impacted are the patient care units. … You want to avoid situations where there is a lot of cross-infection within a care setting. … KH: Let’s move on to talking about alternative care sites. Can you please describe what these are? … Without the staff, nobody's getting care, so it's
inherently a patient safety issue.
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - balance, independence and objectivity in all its CME activities to promote improvements in health care … pathological fracture” and it was determined she needed pediatric orthopedics specialty care. … The patient
continued to recover and was monitored appropriately in the intensive care unit. … medications, expressed in both mass and
volume units, have been recommended for pediatric critical care … Pediatr Crit Care Med. 2016;17(12):1109–1116. [Free full text]
18. Josephy CP, Vinson DR.
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - a prescription opioid overdose in 2015, and thousands more were hospitalized or required emergency care … Evidence-based guidelines for the treatment of chronic pain in primary care, such as those developed … Sometimes that's a nuisance, but I've had people die under my care from that. … They had an encounter with the health care system. … RW : Do you think the health care system is set up to manage this problem?
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - or the care of loved ones. … J Ambul Care Manage. 2012;35:118-128. [go to PubMed]
2. … Qual Saf Health Care. 2010;19:e10. [go to PubMed]
14. … Med Care Res Rev. 2005;62:601-616. … families, and health care professionals.
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - Sometimes that's a nuisance, but I've had people die under my care from that. … But if a patient like that comes into my care, the easiest thing you can do is just to keep them on it … They had an encounter with the health care system. … RW : Do you think the health care system is set up to manage this problem? … Immediately what pops into mind is a 13-minute primary care clinic visit when the patient has 5 other
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - much smaller.( 5,7 ) When interviewing patients prior to contrast material injection, many health care … 1, 2003
View More
See More About The Topic
Hospitals
Health Care
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Acute Crit Care. 2021;36(4):374-379. [Free full text]
10. … Respir Care. 2021;66(1):156-169. [Free full text]
15. Rackley CR. … Respir Care. 2020;65(6):832-846. [Free full
text]
16. … Skills: Endotracheal tube and tracheostomy tube cuff care (respiratory therapy). … Respir Care. 2015;60(2):183-190.
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - medical error.( 2 ) However, patients generally want to be informed about even minor errors in their care … For most health care providers—in other words, those who are not advanced narcissists—it's more the fear … I would say, "Yes, there was an error in the course of her care. … However, I don't stress that very much when I talk to health care professionals because, quite frankly … Truthful and comprehensive error disclosure is a paradigm change for health care professionals and legal
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - ensure balance, independence and objectivity in all its CME activities to promote improvements in health care … Wound care was initiated with home health nurses performing wet-to-dry dressing changes. … wound appeared to have dehisced, and the patient was readmitted to the hospital for advanced wound care … If these measures fail, escalate care promptly to include interventions such as an epidural blood patch … Spinal sealant system provides better intraoperative watertight closure than standard of care during
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - Laryngospasm may occur during monitored anesthesia care (MAC) and all staff administering sedation, … A high level of preparation and flexibility is
indispensable for providing safe anesthesia care. … Qual Saf Health Care. 2005;14(3):e3. [Free full text]
7. Gavel G, Walker RWM. … Anaes Crit Care Pa. 2014;14:47-51. [Free full
text]
8. Li Y, Bohringer C, Liu H. … Double standard: why electrocardiogram is standard care while
electroencephalogram is not?
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - example, in a briefing the surgeon might ask the anesthesiologist if there are any particular patient care … Take-Home Points All health care providers performing invasive procedures must adopt the Joint Commission … Each institution should decide how the Universal Protocol and time out are documented, but care must … Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care … 2004
View More
See More About The Topic
Operating Room
Health Care
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - Director of the Tennessee Hospital Association PSO about how the unique circumstances
surrounding care … It serves 58 providers,
most of which are acute care hospitals. … RD: We saw that different processes were needed related to sepsis care. … And even standard care, like catheter care and central
line care, was changed dramatically for a person … They set up incredible systems, very quickly, and provided
excellent patient care.
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Qual Saf Health Care. 2010;19:e52. [go to PubMed]
3. Silver J. … Acute Care Edition. Side tracks on the safety express. … Crit Care Nurse. 2010;30:21-29. [go to PubMed]
14. Federwisch A. … , health insurance, and health care financing programs. … This particular resource is focused on inpatient hospital care.
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - severe lung damage and the anticipated need for very slow weaning from the ventilator, the critical care … Nurs Crit Care . 2019; 24(2):83-88. [ Available at ] Scholfield DW, Warner E, Ahmed J, et al. … Multidisciplinary tracheostomy care: how collaboratives drive quality improvement. … Respir Care . 2021;66(1):156-169. [ Free full text ] Rackley CR. … cuff care (respiratory therapy).
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - A high level of preparation and flexibility is indispensable for providing safe anesthesia care. … Their assistance is invaluable for providing safe patient care when an unanticipated emergency arises … Qual Saf Health Care . 2005;14(3):e3. [ Free full text ]
Gavel G, Walker RWM. … Anaes Crit Care Pa. 2014;14:47-51. [ Free full text ]
Li Y, Bohringer C, Liu H. … Double standard: why electrocardiogram is standard care while electroencephalogram is not?
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - 1 ) While such drawbacks are inherent in technology, our poor understanding of technology in health care … RW : Can you give us your favorite example or two from outside of health care? … ET : One typical one that bridges health care and consumer behavior is the filter cigarette. … ET : I can understand that, and I think there's another dimension in health care. … October 8, 2014
Studying the technical work of emergency care.