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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - assess patients. … safety risk. … Safety Research and Practice, and the State of Massachusetts Betsy Lehman Center for Patient Safety, … September 23, 2020
Cybersecurity in health is an urgent patient safety concern: we can … learn from existing patient safety improvement strategies to address it.
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Approaches to Improving Safety
Palliative Care and Hospice as Patient Safety
Systems-based interprofessional … Together, the two approaches to care improve quality, including patient safety. … When
a patient is not on hospice, safety concerns focus on keeping the patient alive and free from complications … While preventing complications remains part of patient safety, preventing
death is no longer a safety … Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
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psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - At the visit, the patient complained of worsening lower extremity edema over the prior few weeks. … The patient was treated with hypertonic (3%) normal saline, potassium repletion, and supportive care. … However, the patient should be monitored closely, and diuretic treatment should be stopped if weight … July 6, 2011
MRI safety: prepare for new guidance. … Transitioning between electronic health records: effects on ambulatory prescribing safety
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - The radial artery, in particular, follows a variable course in different patients. … Approaches to Improving Patient Safety
Avoid injecting drugs and air bubbles into arterial lines
All … Christian Bohringer, MBBS
Consulting Editor, AHRQ, Patient Safety Network (PSNet)
Professor of Clinical … The Pennsylvania Patient Safety Authority. … Tubing Misconnections: Making the Connection to
Patient Safety.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - The nurse informed the physician that the patient was having significant pain and liquid opioids had … For added safety, the pharmacist personally retrieved, labeled, and delivered the drug and a calibrated … A covering nurse checked on the patient and found him unconscious—a code blue was called. … Pa Patient Saf Advis. 2013;10:27-33. … he was taking
Solutions:
Patients and families should be empowered to ask questions about their medications
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - adult hospital, investigators at Brigham and Women’s Hospital found
that cross-coverage of unfamiliar patients … communication develop, as working conditions improve, and as the culture of medicine gradually becomes
more safety-conscious … this particular scenario from unfolding:
Health care providers should establish a system to provide patients … Designated ED staff (perhaps triage nurses) should confirm the reason for referral of all patients sent … The nature of adverse events in hospitalized patients.
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - A new hospitalist assumed care of the patient on the third hospital day. … The mortality rates for thyroid storm range from 10%–75% of
hospitalized patients.(1)
Myxedema coma … presents in older
women—frequently in the winter months—but it can occur in both sexes and in younger patients … amiodarone-induced thyrotoxicosis or
amiodarone-induced hypothyroidism may develop in 14% to 18% of all patients … Notification of abnormal lab test results in an electronic medical
record: do any safety concerns remain
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - If you are anxious about treating other physicians, you should not accept such patients. … Between two worlds: physicians as patients. In: Sickness and healing. … August 16, 2017
Learning from patient safety incidents involving acutely sick adults … safety. … Related Resources
Annual Perspective
Improving Diagnostic Safety
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - better assess patients. … safety risk. … Safety Research and Practice,
and the State of Massachusetts Betsy Lehman Center for Patient Safety … j.jad.2018.02.045
https://doi.org/10.1001/jama.294.16.2064
https://www.jointcommission.org/resources/patient-safety-topics … Why therapists stopped creating no-harm contracts for safety. Pollen.
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - Of course, EHR-related patient safety exists as a subset of an organization's overall safety programs … Identification and Prioritization of HIT Patient Safety Measures. … Measuring and improving patient safety through health information technology: The Health IT Safety Framework … Health IT and patient safety: a paradigm shift to shared responsibility. … Patient safety goals for the proposed Federal Health Information Technology Safety Center.
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - Although the majority of patients seen in EDs present directly or are brought by ambulance, many are … The 2008 Joint Commission Patient
Safety Goal 2E requires all health care providers to "implement a … As with all transfers of care, this should be done in
accordance with the 2008 Patient Safety Goal 2E … [Available at]
6. 2008 National Patient Safety Goals Hospital Program. The Joint Commission. … The Joint Commission Accreditation Program: Ambulatory Health Care National Patient Safety Goals.
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - safety when managing hospitalized patients on home insulin pumps
The Case
A 14-year-old girl … Safety
In the case outlined above, patient/caregiver resistance coupled with provider knowledge … recognition of hypoglycemia. 1 0 However, there are currently insufficient data on clinical outcomes and safety … to recommend widespread CGM use in hospitalized patients. 22,23 Even if the patient uses a CGM, point-of-care … An Overview of Safety Issues on Use of Insulin Pumps and Continuous Glucose Monitoring Systems in the
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - Safety and sedation-associated adverse event reporting among patients undergoing endoscopic cholangiopancreatography … Procedural sedation for adult patients: an overview. … safety. … November 2, 2011
Perspective
Establishing a Safety Culture … November 15, 2023
Facilitators and barriers to the implementation of surgical safety
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - We spoke with him about telemedicine and patient safety.
Dr. Robert M. … Telemedicine and Patient Safety
September 1, 2016
Perspective
A paradigm shift is ongoing … Suggestions to increase patient safety in telemedicine include: (i) patient safety awareness should permeate … Doing so should allow us to use these technologies to improve patient safety. … Patient safety and telephone medicine: some lessons from closed claim case review.
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - The therapeutic index (ratio between toxic dose and therapeutic dose, a measure of the relative safety … April 1, 2006
AHRQ's Hospital Survey on Patient Safety Culture: psychometric … Safety (TOPS) experience. … outcomes: results from the Triad for Optimal Patient Safety (TOPS) project. … Safety and Adherence to Self-Administered Medications
July 1, 2011
View More
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - to chronic opioid use in 20% of these patients, but can also be idiopathic in nature. 5 All patients … Barnes, MD, FACEP Consulting Editor, AHRQ, Patient Safety Network (PSNet) Health Science Clinical Professor … An accuracy study in critically ill patients. … Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety … June 12, 2024
Patient Safety Innovations
Journal
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - Efforts to improve safety of patients and workers led to the introduction of Universal Precautions (now … and Patient Safety Target
When the increasing incidence of latex allergy was initially identified, … The Pennsylvania Patient Safety Authority (PPSA) undertook such research and published the results on … Individuals involved in patient safety should work on such automatic preventions to avert adverse events … September 23, 2020
Emergency medicine quality improvement and patient safety curriculum
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - The Commentary Between 370,000 and 750,000 hospitalized patients suffer a cardiac arrest and undergo … Taekman, MD Assistant Professor of Anesthesiology Director, Human Simulation and Patient Safety Center … Wright, PhD Assistant Professor of Anesthesiology Human Simulation and Patient Safety Center Duke University … Anaesthesiology as a model for patient safety in health care. … January 3, 2017
Optimizing Pediatric Patient Safety in the Emergency Care Setting.
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - Approach to Improving Safety & Patient Safety Target
Multiple studies have demonstrated the safety … must be carefully considered alongside important patient safety factors. … Even patients who are monitored overnight after surgery, such as the patient in Case #1, occasionally … score matched analysis of 16,370 patients. … safety course for health professions and related sciences students.
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Approaches to Improving Patient Safety
Avoid and discourage working while tired
Clinicians should avoid … Christian Bohringer, MBBS
Consulting Editor, AHRQ, Patient Safety Network (PSNet)
Professor of Anesthesiology … Patient safety, resident education and resident well-being
following implementation of the 2003 ACGME … Patient safety outcomes under flexible and standard resident
duty-hour rules. … The fatigued anesthesiologist: a threat to patient safety?