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Showing results for "patient safety indicators".
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3721. Spotlight Case September 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
      September 01, 2003 - If so, did deviation have potential to cause patient harm? … Factors Patient condition Clinician–patient communication Availability/accuracy of test results … Organization/Management Financial resources Goals, policies, and standards Safety culture and priorities … : The 5 “C’s” Communication Team members communicate effectively/efficiently with each other, the patient … critical units Communication failures contributed to 16% (20/98) operating room events in anesthesia safety

3722. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet
      psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
      August 01, 2012 - Safety Patients who require anticoagulant and/or antiplatelet therapy to minimize thrombotic risk are … Safety of percutaneous endoscopic gastrostomy in high-risk patients. … AHRQ Patient Safety Network. Accessed November 6, 2023. [ Free full text ] Pinto A, Brunese L. … Patient safety at handoff in rehabilitation medicine. … on patient safety of enabling the digital transfer of patients' prescription information in the English

3723. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49474/psn-pdf
      March 01, 2005 - Upon transfer, the patient was febrile with stable vital signs. … research, experienced personnel, and technological and mechanical aides—must be applied to ensure safety … Surgery in the obese patient presents special challenges. … What Can Be Done to Improve Quality and Safety in the Care of the Obese Patient? … Management of the obese critically ill patient.

3724. Transfusion Overload | PSNet
      psnet.ahrq.gov/web-mm/transfusion-overload
      September 23, 2020 - At the time, the patient remained weak but had no new symptoms. … The patient was given the blood and the diuretics. … If the patient is stable, blood may not be needed. … Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety … transfusion safety.

3725. In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
      October 28, 2020 - KH : What about impact on other safety concerns? … You put in a system of delivery of fluids for patients. … care and ensuring the safety of both the patient and the healthcare workforce. … risks associated with usual care needs for this patient population, such as falls and pressure ulcers … Colton Hood about Remote Patient Monitoring March 15, 2023 The Lancet Commission

3726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49543/psn-pdf
      September 01, 2007 - against the physician's admission, transfer, and/or discharge orders.(14) Given the patient safety … risk posed by medication discrepancies during transitions of care, leading patient safety organizations … Patient-physician communication at hospital discharge and patients' understanding of the postdischarge … Joint Commission. 2006 Critical access hospital and hospital national patient safety goals. … OSF healthcare's journey in patient safety. Qual Manag Health Care. 2004;13:53-59.

3727. Debriefing for Clinical Learning | PSNet
      psnet.ahrq.gov/primer/debriefing-clinical-learning
      September 15, 2024 - safety and patient care based on a recent event or a hypothetical situation. 1 Debriefing is an important … situation may provide cause for a debrief, highly emotional resuscitations, those involving pediatric patients … They decide to focus on the patient and staff safety concerns and identify gaps in systems, teamwork, … Safety January 31, 2024 Nature of blame in patient safety incident reports: … Patient Safety Primers Improving Patient Safety and Team Communication

3728. The Dropped "No" | PSNet
      psnet.ahrq.gov/web-mm/dropped-no
      October 30, 2019 - Fortunately, the patient tolerated the procedures well. … and aviation models to improve safety and quality. … June 9, 2010 Perspective Patient and Family Roles in Safety … September 23, 2020 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of

3729. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49840/psn-pdf
      September 01, 2018 - in their own safety, including programs to facilitate patient-reported medication adverse events and … Lucier, MD, MBA, MPH Director of Quality Improvement and Patient Safety Hospital Medicine Unit Department … Patient Safety Primer: Patient Engagement and Safety. … www.ncbi.nlm.nih.gov/pubmed/22733210 https://www.ncbi.nlm.nih.gov/pubmed/22007045 https://psnet.ahrq.gov/primer/patient-engagement-and-safety … https://psnet.ahrq.gov/primer/patient-engagement-and-safety https://www.ahrq.gov/policy/electronic/disclaimers

3730. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49861/psn-pdf
      May 01, 2019 - The patient was tachycardic (heart rate 100 beats per minute), but not hypotensive. … The patient quickly lost his pulse and a code was called. … The use of standardized handoff tools has been shown to decrease adverse events and improve safety.( … 19) Implementing such a tool may have helped the patient in this case. … Lawrence Center for Quality and Safety Assistant Professor of Emergency Medicine, Harvard Medical School

3731. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865454/psn-pdf
      March 27, 2024 - In addition to specific health outcomes, patients report having better experiences with their care when … the culture of patient safety is strong. … , it can improve behaviors related to patient safety. … National Steering Committee for Patient Safety. Declaration to advance patient safety. … https://www.ihi.org/initiatives/national-steering-committee-patient-safety/declaration-advance-patient-safety

3732. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest | PSNet
      psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
      February 01, 2023 - Approach to Improving Safety & Patient Safety Target  Protocol-based management of medical problems … are key points of potential intervention for ensuring patient safety.  … Shift-to-shift handoff effects on patient safety and outcomes.  … Management of Sepsis May 31, 2023 Patient Safety Innovations … and Quality April 26, 2023 Patient Safety Innovations

3733. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866578/psn-pdf
      August 28, 2024 - safety.11 Approaches to Improving Safety  Optimize Human Factors Engineering Clinicians in both the … Reported medication events in a paediatric emergency research network: sharing to improve patient safety … Racial/ethnic disparities and patient safety. Pediatr Clin North Am. 2006;53(6):1197-1215. … Human factors engineering and patient safety. … Minimizing medication errors in pediatric patients. US Pharm. 2018;44(4):20-23.

3734. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857061/psn-pdf
      November 27, 2023 - Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 … Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety . … safety into classroom and clinical instruction, and how this affects patient safety as a whole. … harm to patients and providers through system and individual performance.” … https://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx

3735. Medication Reconciliation: Whose Job Is It? | PSNet
      psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
      May 01, 2018 - against the physician's admission, transfer, and/or discharge orders.( 14 ) Given the patient safety … risk posed by medication discrepancies during transitions of care, leading patient safety organizations … Patient-physician communication at hospital discharge and patients' understanding of the postdischarge … Joint Commission. 2006 Critical access hospital and hospital national patient safety goals. … OSF healthcare's journey in patient safety. Qual Manag Health Care. 2004;13:53-59.

3736. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60542/psn-pdf
      May 27, 2020 - Examples of tools in the toolkit include: the daily Safety Huddles Tool,22 weekly Patient Safety Leadership … increase patient safety awareness, improve the identification of patient safety issues, and reduce … of patient safety events.   … Patient Safety Essentials Toolkit. Boston, MA: Institute for Healthcare Improvement. … The Joint Commission Journal on Quality and Patient Safety. 2016;42(12):545-AP3.

3737. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - commentary describes the appropriate evaluation for acute abdominal pain, the importance of imaging in patients … The commentary highlights the importance of thorough neurological investigation of patients presenting … adult, and the limitations of non-contrast brain CT for identifying TIA or early ischemic strokes in patients … safety during spine surgery. … can enable care team members to voice concerns about patient safety. 

3738. The Consequences of Miscommunication Regarding a Possible Artifact | PSNet
      psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
      May 11, 2019 - Approach to Improving Safety & Patient Safety Target Given the importance of communication between … safety. … should be incorporated into a systems-level model for improving patient safety. … the patient and the referring clinician, and between the patient and the radiologist. 12 Take-Home … Available at: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/ .

3739. An Obstructed View | PSNet
      psnet.ahrq.gov/web-mm/obstructed-view
      August 07, 2019 - 28, 2023 Investigating workplace support and the importance of psychological safety … March 13, 2024 National survey of patient safety experiences in hospital medicine during … January 10, 2024 Patients' perspectives on quality and patient safety failures: lessons … May 8, 2024 View More Related Resources Patient Safety … Innovations The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and

3740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865412/psn-pdf
      March 27, 2024 - The psychiatric prodromal concept also may lack predictive value, in that many patients (eventually) … Approaches to Improving Patient Safety The tragedy in this case is that there was clinical suspicion … James Bourgeois, OD, MD Consulting Editor, AHRQ, Patient Safety Network (PSNet) Professor of Psychiatry … https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review https … Neuropsychiatric lupus in late- and early-onset systemic lupus erythematosus patients: a systematic