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Showing results for "patient safety indicators".
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3661. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet
      psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
      August 21, 2016 - In fact, abused patients often have a delayed presentation. … Approach to Improving Safety Get a Head CT First for Evaluation of Possible AHT In this case, an ultrafast … Radiologic head CT interpretation errors in pediatric abusive and non-abusive head trauma patients. … Safety October 1, 2017 WebM&M Cases When the … safety in the hospital: a mixed methods study.

3662. Pocket Syringe Swap | PSNet
      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.

3663. Psn-Pdf (pdf file)
      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

3664. Psn-Pdf (pdf file)
      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

3665. Too Hot For Comfort | PSNet
      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

3666. Picking Up the Cause of the Stroke | PSNet
      psnet.ahrq.gov/web-mm/picking-cause-stroke
      August 07, 2024 - The physicians caring for the patient assumed the PICC was safe to use, and the patient began receiving … How best to use PICCs is an important clinical and safety question. … Safety Enhancement Program and Center for Clinical Management Research of the VA Ann Arbor Health System … J Patient Saf. 2015 Nov 10; [Epub ahead of print]. [go to PubMed] 4. … Do clinicians know which of their patients have central venous catheters?

3667. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet
      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

3668. Implementing a Fall Prevention Program | PSNet
      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

3669. Psn-Pdf (pdf file)
      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.

3670. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
      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

3671. Eptifibatide Epilogue | PSNet
      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.

3672. Too Tight Control | PSNet
      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

3673. Psn-Pdf (pdf file)
      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

3674. Psn-Pdf (pdf file)
      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.

3675. Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective | PSNet
      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?"

3676. Patient Safety in Office-Based Care Settings | PSNet
      psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
      January 31, 2024 - safety incidents do occur, and given the volume of patients receiving care in office-based settings, … safety hazards because patients may be prescribed medications from many different providers, and these … Notably, better communication between clinicians and patients may reduce patient-reported non-routine … , especially the culture of patient safety.  … Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients.

3677. An Inadvertent Bolus of Norepinephrine. | PSNet
      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

3678. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
      January 01, 2024 - safety risks inherent to wounds contaminated by foreign material. … antibiotic treatment (termed “prophylactic” by the authors) for patients with non-bite wounds. … For some patients, probably including the one in this case, even delayed closure is not feasible or may … Alternatively, patients should be instructed to return to the index ED for re-evaluation. 49 49 … Take Home Points 50 Take-Home Points (1) 51 Evaluate all patients for their risk of wound infection

3679. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)
      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

3680. The Other Side | PSNet
      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