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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - construct—which includes oral communication, skills and tendencies, and understanding of oral communication … problem, particularly if one is working in a public hospital, I don't advocate for direct measurement or screening … So developing standards and verification tools for prescription labels or prescription labeling systems … December 19, 2017
Pictograms, units and dosing tools, and parent medication errors: a … November 26, 2014
Liquid medication errors and dosing tools: a randomized controlled
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Summary
Care management staff (such as nurses, community health workers, health coaches, social workers … staff) enters the client's clinical information and medication list into a computerized risk assessment screening … The top problems were systematized into protocols and a preliminary screening algorithm for the randomized … Use opt-out approach: HomeMeds risk screening and problem resolution is important and should be included … July 1, 2020
Oral chemotherapy: a home safety educational framework for healthcare providers
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - During her ED visit, her symptoms resolved with sublingual nitroglycerine and a "GI cocktail" (an oral … Department of Health and Human Services. … Department of Health and Human Services. … Use of administrative data to find substandard care: validation of the complications screening … September 29, 2017
WebM&M Cases
Failed Interpretation of Screening
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psnet.ahrq.gov/node/33680/psn-pdf
March 22, 2009 - construct—which includes oral communication, skills and tendencies, and understanding
of oral communication … problem, particularly if one is working in a public hospital, I don't advocate for direct
measurement or screening … The last lever is health IT. … Health IT can go one of two ways with respect to this health literacy issue. … So developing standards and verification tools for prescription labels or prescription
labeling systems
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - when the patient's last hemoglobin was checked prior to her
planned surgery or that any additional oral … exposure to blood increase the risk of RBC
alloimmunization.(11) Routine prenatal care should include screening … Stanford, CA: California
Department of Public Health, Maternal, Child and Adolescent Health Division … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - as a tablet); two strengths that are shared (5 mg and 10 mg); the same route of administration (both oral … Zyprexa *** § drugs have similar action or indication (eg, glipizide and glyburide are both oral … Department of Health and Human Services. … Department of Health and Human Services. … Care Providers
Non-Health Care Professionals
Medicine
Mental Health Care (Psychiatry and Clinical
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - order sets that highlight proper patient selection (opioid-naïve versus opioid-tolerant), emphasize oral … Serum bicarbonate level improves
specificity of STOP-Bang screening for OSA. … Am Health Drug Benefits. 2008;1(5):28-35.
36. … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - opioid safety
through:
– Proper patient selection (opioid-naïve versus opioid-tolerant)
– Emphasis on oral … Serum bicarbonate level improves specificity of STOP-Bang screening for OSA. … Am J Health Syst Pharm.
2008;65(12):1184-1191.
30. Jungquist CR, Smith K, Nicely KL, Polomano RC. … Am
Health Drug Benefits. 2008;1(5):28-35.
36.
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - We do have some tools that will allow us to identify people who are at particularly high risk of being … Risk mitigation measures, such as urine toxicology screening, patient contracts, and risk assessment … tools, are also increasingly popular, although there is limited evidence regarding whether or how these … While there are no perfect risk assessment instruments, universal screening and triaging of chronic opioid … users with tools such as the Screening, Brief Intervention, and Referral to Treatment model also represent
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - During the meeting, attendees would talk about the TeamSTEPPS program, the tools and materials, and how … because there’s a physical trauma of needing to have repeated diagnostic or preventative testing and screening … Sarah Mossburg : I’m curious about any strategies or tools that providers working in office-based care … The mitigation strategy of incorporating individualized fall risk screening to identify patients most … However, building awareness of frequently misdiagnosed conditions in primary care and developing tools
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - Such efforts must be accompanied by increased use of alternative pharmacologic and nonpharmacologic tools … Risk mitigation measures, such as urine toxicology screening, patient contracts, and risk assessment … tools, are also increasingly popular, although there is limited evidence regarding whether or how these … While there are no perfect risk assessment instruments, universal screening and triaging of chronic opioid … users with tools such as the Screening, Brief Intervention, and Referral to Treatment model also represent
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - order sets that highlight proper patient selection (opioid-naïve versus opioid-tolerant), emphasize oral … Serum bicarbonate level improves specificity of STOP-Bang screening for OSA. … Am Health Drug Benefits. 2008;1(5):28-35. … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Case #2:
A 76-year-old man with recurrent lymphoma and an oral tumor mass at the base of the tongue … Patient information and risk assessment may also be gathered via screening assessments, patient-entered … record, screening assessment,
and an in-person visit at a preoperative evaluation clinic, if available … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Case #2: A 76-year-old man with recurrent lymphoma and an oral tumor mass at the base of the tongue … Patient information and risk assessment may also be gathered via screening assessments, patient-entered … record, screening assessment, and an in-person visit at a preoperative evaluation clinic, if available … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - Do you take on some responsibility for your own health and well-being, and for
your mental health? … All of these determinants of health impact health
and well-being greatly. … During the meeting, attendees would talk about the
TeamSTEPPS program, the tools and materials, and … because there’s a
physical trauma of needing to have repeated diagnostic or preventative testing and screening … Sarah Mossburg: I’m curious about any strategies or tools that providers working in office-based care
-
psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Process Variation
The health care professionals in this case failed to accurately review and document … Allowing for at least two
health care professionals in verifying the identity, dosage, and instructions … done in
instances when the medication is hard to obtain (e.g., Revlimid [lenalidomide], a specialty oral … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - The mitigation strategy of incorporating individualized fall risk screening to identify patients most … However, building awareness of frequently misdiagnosed conditions in primary care and developing tools … practices and tools designed to increase the effectiveness of communication to improve patient safety … Team Strategies and Tools to Enhance Performance and Patient Safety at primary healthcare units: Effect … because there’s a physical trauma of needing to have repeated diagnostic or preventative testing and screening
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - She stabilized and was discharged home on oral amiodarone therapy. … admissions for presumed COPD exacerbations requiring treatment with bronchodilators, antibiotics, and oral … Department of Health and Human Services. … Department of Health and Human Services. … 1, 2017
WebM&M Cases
Failed Interpretation of Screening
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - We ultimately
https://psnet.ahrq.gov/issue/development-and-implementation-oral-sign-out-skills-curriculum … RW: How important were the IT tools? … There's certainly still
huge potential and room for improvement and ease in creating handoff tools. … see the value and importance of having these types of tools available. … techniques, huddles, or having a formal debrief to go through things were all
relatively poorly applied in health
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - location-related error , where the abnormality was outside the anatomic area of focus (i.e., runoff of oral … number of care teams performing gastrostomy procedures where possible, to standardize communication tools … Department of Health and Human Services. … Department of Health and Human Services. … May 25, 2016
A scoping review of communication tools applicable to patients and their