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3801. Right? Left? Neither! | PSNet
      psnet.ahrq.gov/web-mm/right-left-neither
      November 16, 2022 - Examples of such defenses include training programs; safety protocols, policies, and procedures; and … Many defenses failed to protect this patient. … Safety March 27, 2024 Patient Safety Innovations … Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 … Annual Perspective Improving Diagnostic Safety and Quality

3802. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60363/psn-pdf
      March 01, 2021 - Use of a patient-centered Personal Health Record: Patient understands and utilizes the Personal Health … The PHR is managed by the patient or by the informal caregiver. … Knowledge of “red flags”: The patient is knowledgeable of indicators that his or her condition is worsening … Innovation Patient Safety Focus CTI focuses on patient empowerment during the care transition process … Use of patient-centered record: Patients need to understand, manage, and use a personal health record

3803. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
      February 26, 2025 - Beyond particular patient safety incidents like medication error or patient misidentification, an academic … Work system design for patient safety: the SEIPS model. … of all the patients currently on the unit. … It gives a view of where the workload is and who might have the most vulnerable patients. … Health Systems for Patient Safety February 26, 2025 Patient Safety

3804. The Evidence-Based Physical Examination as a Patient Safety Practice | PSNet
      psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
      November 01, 2012 - The Evidence-Based Physical Examination as a Patient Safety Practice Steven McGee, MD | November 1, … The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet]. … The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet]. … That disappoints me, and I think it has both cost and patient safety consequences. … The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet].

3805. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. | PSNet
      psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
      August 21, 2005 - The surgical consultant arrived and told the patient that amputation of the limb might be needed. … The patient safety issues center on confirming the aortic valve-associated thrombosis, providing appropriate … Approach to Improving Safety and Patient Safety Target Although we do not know this patient’s INR value … safety. … Related Resources Annual Perspective Improving Diagnostic Safety

3806. In Conversation With… Michelle Mello, MPhil, JD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
      July 01, 2017 - We spoke with her about legal issues in patient safety. Dr. Robert M. … How did the dynamic of that relationship change when the patient safety field became a thing 15 years … We're going to continue to take care of patients." … Then there's the possibility that plaintiffs' attorneys and their clients will come to expect that when … Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023

3807. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49678/psn-pdf
      March 01, 2013 - safety is at risk. … Although there is obvious safety benefit of taking these complex weight-based treatment calculations … of reaching patients. … How can information technology improve patient safety and reduce medication errors in children's health … Weighing pediatric patients in kilograms. Position statement. [Available at] 15.

3808. In Conversation With... Georgia Galanou Luchen, Pharm. D. | PSNet
      psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
      October 24, 2021 - safety include the patient education component. … This again affects the timing and safety of working with patients. … These are all factors that play into patient safety. … Patient safety is best achieved in organizations that have a strong culture of safety . … Organizations with a strong culture of safety are not only better positioned to ensure patient safety

3809. After-Visit Confusion | PSNet
      psnet.ahrq.gov/web-mm/after-visit-confusion
      August 21, 2007 - Patient portals are secure Web-based platforms that allow patients to view information about their ongoing … The impact of eHealth on the quality and safety of health care: a systematic overview. … Safety Research December 1, 2003 WebM&M Cases … Related Resources Annual Perspective Improving Diagnostic Safety … Emergency Departments Ambulatory Clinic or Office Health Care Providers Quality and Safety

3810. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
      January 01, 2020 - should be able to: Appreciate that primary care doctors (PCPs) may be caring for an increasing number of patients … The safety committee felt if these components of the exam had been performed, the providers might have … are likely to be increasingly managing neurologic conditions Limited data exist to suggest how often patients … —The diagnosis made in 3781 new patients. … Bringing diagnosis into the quality and safety equations.

3811. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
      January 01, 2022 - – In patients with schizophrenia, patients often have poverty of speech and thought that prevent … – Patients with delusions may believe a doctor is trying to harm the patient instead. … Can the patient decide? Evaluating patient capacity in practice. … to Improving Systemic Safety (2) Approach to Improving Systemic Safety (3) Approach to Improving Systemic … Safety (4) Approach to Improving Systemic Safety (5) Approach to Improving Systemic Safety (6) Take

3812. Discharge Instructions in the PACU: Who Remembers? | PSNet
      psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
      August 05, 2009 - For verbal communication with patients, it is important to limit the quantity of information that patients … this case highlights the importance of pursuing innovative approaches that can enhance the quality and safety … May 16, 2012 Improving departmental psychological safety through a medical school-wide … Health system redesign of cardiac monitoring oversight to optimize alarm management, safety … More See More About The Topic Hospitals Health Care Providers Quality and Safety

3813. Identifying Safety Events in the Prehospital Setting | PSNet
      psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
      May 16, 2022 - monitoring patient safety in the prehospital setting suggests that safety surveillance systems have … Patient Safety Incidents Perhaps one sign of EMS’s emergence in the field of patient safety is the … safety, and those are relatively new; what are some other ways that historically patient safety has … version of the surveys on patient safety, or the EMS SOPS. … The project is huge, not just for patients, but for providers, as well as the communities.

3814. In Conversation With… Sidney Dekker, MA, MSc, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
      February 26, 2025 - Safety: A Human Factors Approach. … Robert Wachter, Editor, AHRQ WebM&M : What got you interested in patient safety? … She gave a calcium chloride overdose to one of her pediatric patients. … RW : Do you think that patients and the citizenry more broadly, the political apparatus, is willing to … If you're the patient or your loved one is the patient, it takes on a completely different nature.

3815. In Conversation with...Richard Ricciardi about Office-Based Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
      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.

3816. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
      January 01, 2024 - Describe some of the considerations for and against administering prophylactic anticoagulation to patients … Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Professionals' Speaking-up Skills … AHRQ Patient Safety Network (PSNet). October 31, 2023. Accessed July 15, 2024. … Patient Safety Issues From Information Overload in Electronic Medical Records.  … [Free full text] Advancing safety with closed-loop communication of test results. Quick Safety.

3817. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865984/psn-pdf
      May 29, 2024 - The patient passed away at home two days later. … with impaired exercise capacity.5 Approach to Improving Safety & Patient Safety Target When approaching … psnet.ahrq.gov//#6 https://psnet.ahrq.gov//#7 https://psnet.ahrq.gov/issue/shift-shift-handoff-effects-patient-safety-and-outcomes-systematic-review … Lastly, ED patient volumes have been steadily increasing, motivating the demand for faster patient triage … Shift-to-shift handoff effects on patient safety and outcomes. Am J Med Qual. 2017;32:34-42.

3818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33864/psn-pdf
      January 01, 2019 - Simulations involving standardized patients are a means to assess selected competencies in patient care … benefit for patients.(9) This finding is superior to the effect sizes for patient outcomes reported … safety (latent safety threats).(16) In that study, researchers made extensive use of simulation before … /psnet.ahrq.gov//#ref1 https://psnet.ahrq.gov//#ref1back https://www.ahrq.gov/professionals/quality-patient-safety … /patient-safety-resources/research/simulation-dictionary/index.html https://psnet.ahrq.gov//#ref2back

3819. Unexpected Drawbacks of Electronic Order Sets | PSNet
      psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
      December 01, 2017 - accompany potassium replacement, and that, by separating out the order sets electronically, an important safety … As an example, in patients with congestive heart failure and chronic kidney disease taking diuretic therapy … ISMP Medication Safety Alert! Acute Care Edition. ISMP develops guidelines for standard order sets. … Mixed results in the safety performance of computerized physician order entry. … December 16, 2020 Computerized prescriber order entry–related patient safety reports:

3820. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
      April 01, 2008 - and more cephalad rib spaces. 13,14 Furthermore, incision or needle insertion should be made in the safety … Approach to Improving Patient Safety Errors in both judgement and technique led to this adverse outcome … safety: past, present, and future. … December 11, 2024 Patient Safety Innovations Rescue Improvement … April 3, 2024 Facilitators and barriers to the implementation of surgical safety checklist