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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022. … Patient Safety
Opioids and benzodiazepines are commonly used medications in the acute care setting. … ensure safety and to avoid
medication dose stacking. … psnet.ahrq.gov//#14
https://psnet.ahrq.gov//#14
https://psnet.ahrq.gov//#13
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking … Classifying safety events related to diagnostic imaging from a safety
reporting system using a human
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Safety Foundation ( 8 ) has issued a set of recommendations intended to improve safety. … Most anesthesiologists believe that during the transfer of relatively unstable patients from the OR to … These patients are just emerging from anesthesia, and are notoriously subject to several abrupt physiological … Effect of bar-code technology on the safety of medication administration. … ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - A Systematic Approach to Improving Patient Safety
This case illustrates how failure to adhere to patient … classification level III or higher.7 Pediatric anesthesiologists are uniquely qualified to care for patients … In the operating room, patients receive greater volumes of fluids at higher administration
rates. … /#2
https://psnet.ahrq.gov//#14
https://psnet.ahrq.gov/issue/safe-surgery-saves-lives-second-global-patient-safety-challenge … .0000000000000112
https://doi.org/10.4103/2229-5151.100890
https://www.who.int/teams/integrated-health-services/patient-safety
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psnet.ahrq.gov/node/49396/psn-pdf
April 01, 2003 - The patient took the medication for about 2 weeks, with no adverse sequelae. … psychiatrists and allergists), and pharmacists must be alert to the possibility of confusion when patients … chance of drug name confusion by adhering to the prescribing
practices above and also by educating patients … Patients should be aware of potential for mix-ups, especially with problem name pairs. … ISMP Medication Safety Alert! Institute for Safe Medication Practices.
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psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - Use in Patients with Pain A Cochrane review of the use of warming therapy in rheumatoid arthritis … (RA) found no objective improvements but also found no adverse reactions and that patients preferred … top of, not underneath, the patient, if possible. … Patient education and instruction regarding use of a heating device are important parts of any therapy … for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - , which can lead to patient harm. … Nicholas Symons, MBChB, MSc
Honorary Clinical Research Fellow
Centre for Patient Safety and Service … Effect of a 19-item surgical safety checklist during urgent operations in a
global patient population … Effect of a comprehensive
surgical safety system on patient outcomes. … Safe Surgery Saves Lives: The Second Global Patient Safety Challenge.
September 2009.
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Frances Healey, RN, PhD Head of Patient Safety National Patient Safety Agency (UK)
References
… Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective … Patient Safety First. The 'How to' Guide for Reducing Harm from Falls. … London, UK: National Patient Safety Agency; 2009. (risk tool calculator [Available at] )
13. … Patient Safety Innovations
Preventing Falls Through
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psnet.ahrq.gov/node/851158/psn-pdf
June 28, 2023 - In a recent
contemporary review of more than 1.09 million diagnostic left heart catheterizations in patients … Although these pigtail catheters have an established safety record, at
least one such product was recalled … If patient safety is jeopardized at any point, all team members should feel free
to voice their concern … periprocedural bleeding and long-term
outcomes following percutaneous coronary intervention in older patients … Validation of the Academic Research Consortium High Bleeding
Risk Definition in Contemporary PCI Patients
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - (including the one presented here) must place a premium on safety. … to distinguish between patient harm in a clinical trial vs. … Safety in clinical trials differs from safety in practice. … Improving medication safety across a multihospital system. … March 4, 2015
Ethical considerations and patient safety concerns for cancelling non-urgent
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - The nurse on duty was harried because he was caring for six patients instead of the usual four. … In the case above, the nurse programming the pump was caring for a larger number of patients than usual … Patient safety and computerized medication ordering at Brigham and Women's Hospital. … March 4, 2011
Collaborative case review: a systems-based approach to patient safety event … June 25, 2010
Creating an integrated patient safety team.
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care … within
quality improvement programs and routine clinical care.(7,8) It is our belief that every ICU patient … passed safety criteria;
(iii) Sedatives were not restarted for patients that passed the SAT and no … longer required them; and
(iv) If the patient clinically required restarting sedatives or analgesics … Reducing patient harm from sedation, immobility, and delirium.
[Available at]
20.
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - Approaches to Improving Patient Safety Effective use of electronic health records (EHRs) One of the strengths … Harnessing the power of problem representation can help us continue to think critically about our patients … that prioritize to-do lists and clarify loose ends may help us coordinate optimal follow-up care for patients … and latent safety threats in adult tracheostomy care. … October 21, 2020
Association of rapid response teams with hospital mortality in Medicare patients
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - AND
PATIENT SAFETY TARGET
16
Approach to Improving Safety and Patient Safety Target (1)
• Multiple … studies have demonstrated the safety of outpatient
thyroidectomy in appropriately selected patients … and Patient Safety Target (2)
• Patients undergoing ACSS are commonly admitted to the hospital
postoperatively … • Even patients who are monitored overnight after surgery, such as the
patient in Case #1, occasionally … and Patient Safety Target (7)
• Any physicians caring for patients undergoing neck surgery or those
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Creating more systematic and proactive follow-up safety nets to ensure patients are improving rather … Safety Research and Practice, and the State of Massachusetts Betsy Lehman Center for Patient Safety, … Efficacy and safety of sirolimus in lymphangioleiomyomatosis. … Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions. … Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - safety issue. … Making Health Care Safer: A Critical Analysis of Patient Safety Practices. … National Patient Safety Agency. NPSA. [ go to related site ]
4. … Enhancing patient safety. London: BMJ Publications; 2001:461-79.
15. … October 14, 2020
The outcomes of recent patient safety education interventions for trainee
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - Lastly, vasopressor titration is another high-profile patient safety topic; however, discussion of the … More research into this patient safety issue should be conducted. … Pennsylvania Patient Safety Advisory. 2014;11(1):1-7. Westbrook JI, Rob MI, Woods A, Parry D. … May 20, 2019
Challenges and strategies for patient safety in primary care: a qualitative … September 28, 2022
Patient perceptions of safety in primary care: a qualitative study
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - Innovation Patient Safety Focus
This innovation reduces preventable readmissions, improve provider … Patient safety concerns arising from test results that return after hospital discharge. … AHRQ Patient Safety E-Newsletter . 2007 Aug 6;(34). … Safety
February 26, 2025
Patient Safety Innovations … Safety Innovations
Transition Coaches® Reduce Readmissions for Medicare Patients With
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
October 01, 2013 - safety issues associated with transgender health
Appreciate the challenges that transgender patients … Am J Public Health. 2001;91:869-872. http://www.ncbi.nlm.nih.gov/pubmed/11392924
10
Patient Safety … Available at http://www.thetaskforce.org/reports_and_research/ntds
11
Patient Safety Concerns: Access … Safety Concerns: Health Risks
Transgender populations among groups at highest risk for HIV infection … J Homosex. 2006;51:53-69. http://www.ncbi.nlm.nih.gov/pubmed/17135115
14
Patient Safety Concerns: Transitioning
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
June 01, 2016 - In my experience, the patient safety message is: "Patient safety standards are not something that health … The certification curriculum in patient safety teaches how to understand key patient safety standards … The patient and family advisory council helps us identify concerns and ideas from patients and families … The National Patient Safety Foundation and the Certification Board for Professionals in Patient Safety … Is it fair to expect our patients to put up with this?"
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - , gaps that endangered patient safety. … Timeliness is an extremely important determinant of patient safety—arguably as important as clinical … would take place in the emergency
department.(16) In addition to improving patient safety and quality … of care and safety. … Managing unnecessary
variability in patient demand to reduce nursing stress and improve patient safety