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8981. Shake Well | PSNet
      psnet.ahrq.gov/web-mm/shake-well
      September 01, 2006 - , thus increasing nurse efficiency while decreasing errors.( 3 ) Any time a patient experiences an … In addition, 6% of doses are not administered; if a patient is not responding to therapy, an omission … There have been cases where patients did not receive a complete dose due to insufficient shaking of antibiotics … In general, physicians should prescribe tablets or capsules (when patients can tolerate them) instead … The effect of extended work hours on patient care provided by medical interns.

8982. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet
      psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
      September 27, 2023 - Put an “NPO” or “Nothing by Mouth” wristband on the patient When patients are mobile, they often move … Test the patient for iron deficiency This patient should have been tested for iron deficiency. … Foreign-body ingestion in patients with personality disorders. … Battery ingestion in children, an ongoing challenge: recent experience of a tertiary center. … Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.

8983. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33857/psn-pdf
      July 01, 2012 - The engagement of patients has enormous potential. … One thing I've concluded from the experience of who naturally and proactively adopted records and who … https://psnet.ahrq.gov/issue/connecting-patients-and-clinicians-anticipated-effects-open-notes-patient-safety-and-quality … https://www.commonwealthfund.org/grants/ournotes-new-strategy-improve-care-complex-patients https:// … It is filtered and shows him maybe 20 patients.

8984. When Healthcare Hurts. | PSNet
      psnet.ahrq.gov/issue/when-healthcare-hurts
      January 15, 2014 - 2019 Examining causes and prevention strategies of adverse events in deceased hospital patients … : a retrospective patient record review study in the Netherlands. … June 16, 2021 Explaining the negative effects of patient participation in patient safety … August 21, 2019 View More Related Resources Learning from experience … June 26, 2019 The Second Victim Experience and Support Tool: validation of an organizational

8985. Diagnostic Errors | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors
      December 01, 2013 - reviews, the researchers estimated that 5% of adults in the US (i.e., more than 12 million individuals) experience … and colleagues used data from the AHRQ Healthcare Cost and Utilization Project to show that, among patients … with stroke, nearly 13% of patients had a visit to the emergency department (ED) within the prior 30 … Just over 1% of patients had a probable missed diagnosis of stroke. … Investigators reviewed the records of medical patients admitted to the pediatric ward or seen in the

8986. Infants at risk: when nurse fatigue jeopardizes quality care. | PSNet
      psnet.ahrq.gov/issue/infants-risk-when-nurse-fatigue-jeopardizes-quality-care
      September 13, 2006 - September 13, 2006 The working hours of hospital staff nurses and patient safety. … February 19, 2010 To be sued less, doctors should consider talking to patients more. … who experience rapid response activation. … Analysis of incident reports from a patient safety organization. … July 17, 2019 Effects on resident work hours, sleep duration and work experience in a

8987. Retained Surgical Items: Causation and Prevention | PSNet
      psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
      January 04, 2024 - Background A retained surgical item (RSI) is a surgical patient safety problem that occurs because of … The patient left the OR to recover in the intensive care unit (ICU), as usual. … many items to safely count under most OR conditions and no alternative management practice Variable experience … patient is included in the decision to remove the fragment or not. … June 12, 2024 Handbook of Perioperative and Procedural Patient Safety.

8988. Side errors in neurosurgery. | PSNet
      psnet.ahrq.gov/issue/side-errors-neurosurgery
      November 17, 2010 - effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients … The introduction of a Neurosurgical Postoperative Checklist improved quality of care and patient … November 20, 2019 "Team time-out" and surgical safety—experiences in 12,390 neurosurgical patients … September 15, 2010 Eight-year experience with a neurosurgical checklist. … August 18, 2010 Spinal surgery and patient safety: a systems approach.

8989. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47177/psn-pdf
      January 23, 2019 - Effect of increased inpatient attending physician supervision on medical errors, patient safety, and … Over the past decade, with the goal of improving both the educational experience and patient safety … safety and the educational experience for housestaff. … care discussions and encounters with newly admitted and existing patients) was compared to standard … directly supervised residents only for new admissions, meeting later in the day to discuss existing patients

8990. In Conversation with...David Marx, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
      October 01, 2007 - be an accountability system that doesn't allow someone to stay in that system if they choose to put patients … to do it, even though I've read the literature and know it's putting my patients at risk. … Based on our experience over the past 6 years, let me give you examples of how you might do this. … If your organization's priority is reducing harm related to misidentification of patients, for example … A name band is applied, and the patient is told that all staff will be asking patients to spell their

8991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33838/psn-pdf
      July 01, 2017 - Many studies have profiled physicians who experience medicolegal events, typically by comparing them … Available evidence suggests that, compared to physicians who experience no or few events, medicolegal … Alternatively, the may signal a much larger quality problem that afflicts many of the patients that … Physician–patient communication. … Medical malpractice experience of physicians. Predictable or haphazard? JAMA. 1989;262:3291-3297.

8992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44648/psn-pdf
      February 14, 2017 - alert overrides in electronic health records: an observational retrospective study of a decade of experience … alert overrides in electronic health records: an observational retrospective study of a decade of experience … rising-drug-allergy-alert-overrides-electronic-health-records-observational- retrospective Alert fatigue is recognized as a barrier to patient … overuse of alerts in health care settings and the need to improve their use to effectively support patient

8993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37966/psn-pdf
      January 15, 2009 - electronic medical records in primary care: lessons learned from health information systems implementation experience … electronic medical records in primary care: lessons learned from health information systems implementation experience … regarding adoption of health information systems in primary care and assessed whether quality and patient

8994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42685/psn-pdf
      December 06, 2013 - An AHRQ WebM&M perspective reveals a nurse's experience with MRSA. … https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature https://psnet.ahrq.gov/perspective … /interpreting-patient-safety-literature https://psnet.ahrq.gov/issue/interrelationship-isolation-precautions-and-adverse-events-acute-care-facility … https://psnet.ahrq.gov/issue/unexpected-hypoglycemia-critically-ill-patient https://psnet.ahrq.gov/issue … /health-care-associated-infections https://psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa

8995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49846/psn-pdf
      November 01, 2018 - Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. … by experienced clinicians; (iii) but experience must emerge in trainees who start without experience … ; and (iv) experience requires the active care of patients. … While they deserve adequate guidance, progression to unsupervised practice may require that they experience … , experience with learners, propensity to trust).(5,6) Challenging learners to engage in new clinical

8996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43239/psn-pdf
      June 11, 2014 - cycle-redemption-medical-error-disclosure-and-apology-program Clinicians who are involved in a medical error and experience … cycle-redemption-medical-error-disclosure-and-apology-program https://psnet.ahrq.gov/issue/medical-error-second-victim https://psnet.ahrq.gov/issue/improving-patient-family-and-clinician-experience-after-harmful-events-when-things-go-wrong

8997. Preventing wrong-site surgery in Minnesota: a 5-year journey. | PSNet
      psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey
      December 19, 2007 - Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. … Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. … The Massachusetts experience. … June 13, 2011 Debriefing for patient safety. … July 30, 2014 Eight-year experience with a neurosurgical checklist.

8998. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37344/psn-pdf
      March 28, 2012 - Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience … Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience … introduction-obstetric-specific-medical-emergency-team-obstetric-crises- implementation-and Implementation of rapid response systems is designed to improve patient

8999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41193/psn-pdf
      August 02, 2012 - found that children in hospitals with high reliance on Medicaid reimbursements are more likely to experience … In addition, pediatric inpatients with Medicaid are more likely than privately insured children to experience … medicaid-hospital-financial-stress-and-incidence-adverse-medical-events-children https://psnet.ahrq.gov/issue/does-patients-payer-matter-hospital-patient-safety-study-urban-hospitals

9000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47189/psn-pdf
      August 17, 2018 - Association of opioid-related adverse drug events with clinical and cost outcomes among surgical patients … Patients receiving higher dose and longer duration of opioids were more likely to experience adverse … mortality risk, and a higher rate of readmissions compared to those who did not experience problems … The authors call for reducing opioid use in acute care, postoperative settings in order to improve patient … psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications