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4101. Cognitive Overload in the ICU | PSNet
      psnet.ahrq.gov/web-mm/cognitive-overload-icu
      June 01, 2005 - safety. … While not an excessive volume of patients, the workload can quickly become unmanageable if multiple patients … safety. … A systematic review of the psychological literature on interruption and its patient safety implications … May 27, 2011 Clinical cognition and biomedical informatics: issues of patient safety.

4102. 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

4103. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49392/psn-pdf
      April 01, 2003 - bed rails.(15) Coagulopathic patients may represent a patient category in whom special precautions are … positionpapers/restrain.shtml common problem throughout our health care system, affecting the quality and safety … evidence for effectiveness is lacking, however.(17) Another solution might be to develop a checklist of safety-related … Walking, however, is critical to patients’ well-being. … Making Health Care Safer: A Critical Analysis of Patient Safety Practices.

4104. Do Not Miss Sepsis Needles in Viral Haystacks! | PSNet
      psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
      March 27, 2024 - The impact of cognitive and implicit bias on patient safety and quality. … Safety Primers National Patient Safety Goals March 27, 2024 … Patient Safety Primers Improving Patient Safety and Team Communication … Strategies and Approaches for Tracking Improvements in Patient Safety April 1, … Safety Primers Telehealth and Patient Safety.

4105. 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

4106. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49432/psn-pdf
      February 09, 2004 - and manage patients. … safety. … safety. … We now have monthly patient safety discussions at residents' report. … Importantly, the vice president for hospital quality and patient safety moderates these sessions.

4107. 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.

4108. Adolescent Diabetes: A Routine Visit? | PSNet
      psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
      November 18, 2016 - , within the limits of state law and patient safety; normalization of the topic as a routine component … safety events and harms during medical and surgical hospitalizations for persons with serious mental … November 18, 2016 Patient, provider, and system factors contributing to patient safety … November 30, 2016 Nurses' perceived skills and attitudes about updated safety concepts … February 1, 2023 Patient identification of diagnostic safety blindspots and participation

4109. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49580/psn-pdf
      March 21, 2009 - Safety Goals (NPSG) to reduce the impact of medication errors on patient safety.(4) This case identifies … patients take medications that should always be avoided.(3,9) A study evaluating medication use in … Glintborg and colleagues found that patients admitted to a hospital in Denmark failed to report 27% … filled by the patient. … [go to PubMed] 4. 2009 Hospitals' National Patient Safety Goals.

4110. Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. | PSNet
      psnet.ahrq.gov/issue/diagnostic-errors-uncommon-conditions-systematic-review-case-reports-diagnostic-errors
      June 19, 2024 - November 9, 2022 Effect of contextual factors on the prevalence of diagnostic errors among patients … March 28, 2018 Culture of safety: impact on improvement in infection prevention process

4111. 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.

4112. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50841/psn-pdf
      January 29, 2020 - https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event Disclosure … the key aspects of the closed-loop blood delivery pathway and how they ensure transfusion recipient safety … The Commentary By Sarah Barnhard, MD Introduction: Transfusion Safety The history of the blood supply … safety event in transfusion services must include: 1. … Emily Cooley Lecture 2002: Transfusion safety in the hospital. Transfusion. 2003; 43:1190- 1199.

4113. 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.

4114. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49665/psn-pdf
      September 01, 2012 - RSIs can result in significant patient morbidity and even mortality.( 3,9,10) Patients can experience … There are no studies that have evaluated the patient safety and economics risk–benefit of introducing … eliminate sponge or instrument RSIs.(21) However, key findings from a number of studies on operating room safety … Cima, MD, MA Vice-chair, Quality and Safety, Department of Surgery Associate Professor of Surgery, … Improving safety in the operating room: systematic literature review of retained surgical sponges.

4115. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
      January 01, 2024 - Approach to Improving Safety & Patient Safety Target 40 Approach to Improving Safety & Patient Safety … & Patient Safety Target (2) • Although the medical history and the physical examination are the bedrock … & Patient Safety Target (3) • Practice-changing laboratory information should be considered for high … & Patient Safety Target (4) • Emerging imaging technologies may be useful in patients presenting with … Safety and efficacy of thrombolysis in telestroke: a systematic review and meta-analysis.

4116. 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

4117. Order Interrupted by Text: Multitasking Mishap | PSNet
      psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
      August 21, 2015 - Describe the benefits of mobile technology to safety, quality, and efficiency. … international normalized ratio (INR) was 1.4 (the INR is a measure of anticoagulation intensity in patients … safety, and care without increasing bedside interruptions. … This is particularly important because the clinical condition of hospitalized patients so often changes … safety.

4118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72835/psn-pdf
      March 10, 2021 - If we think about patient family engagement as an active patient safety strategy, as an engaged person … It’s using that patient connection as an additional resource and as a strategy to improve safety and … CMS mandated patient family engagement in the QIOs and in the Partnership for Patients (PfP) and Hospital … KH: If we could go to patient safety programs, the federal partners, or other organizations leading patient … I think we need to be thinking about what our quality improvement and patient safety initiatives achieved

4119. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy | PSNet
      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

4120. 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