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4121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49506/psn-pdf
      March 01, 2006 - The patient was admitted for pain control with intravenous morphine and started on patient-controlled … radiology residents have traditionally provided preliminary interpretations during off- hours for patients … To provide the safety net for these resident preliminary readings while protecting the residents' training … Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients … improper bolus timing (which may obscure PE or, occasionally, simulate PE), mottle (seen in large patients

4122. Psn-Pdf (pdf file)
      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.

4123. 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?

4124. 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

4125. 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

4126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842923/psn-pdf
      February 01, 2023 - safety practices. … This finding raises questions about the safety of performing post-cardiac open surgical procedures in … Multipronged Approach to Improving Safety Epidemiology After identifying this case, the hospital’s … unit manager and representatives from units such as Environmental Services, Environmental Health & Safety … An investigation of Aspergillus cardiac surgical site infections in 3 pediatric patients.

4127. 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.

4128. 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

4129. Compare and Contrast | PSNet
      psnet.ahrq.gov/web-mm/compare-and-contrast
      July 16, 2019 - Therefore, if a contrast study is what is required to appropriately manage a patient at patient at high … safety outcomes among early-career hospital nurses. … patient safety in hospital nurses. … safety events from home. … July 8, 2020 Engaging patients and informal caregivers to improve safety and facilitate

4130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33661/psn-pdf
      December 01, 2007 - Goodbyes are said as patients pack their belongings and return home. … More importantly, what can be done to improve patient safety in this setting? … However, other domains crucial to patient safety and continuity of care—such as discharge medications … Patients' understanding of their treatment plans and diagnosis at discharge. … safety and continuity of care.

4131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49697/psn-pdf
      December 01, 2013 - The anesthesiologist then injected 2 mg of midazolam to sedate the patient. … The patient did not experience any obvious harm from the uncontrolled inhalation induction. … while overdoses of inhalational anesthetics could be administered in other ways, thus bypassing such a safety … etiology is multifactorial and includes a distracting environment and production pressure that limit safety … Patient injuries from anesthesia gas delivery equipment: a closed claims update.

4132. New Insights About Team Training From a Decade of TeamSTEPPS | PSNet
      psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
      February 01, 2017 - The relation between teamwork and patient safety. In: Carayon P, ed. … Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. … TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. … In: Advances in Patient Safety: New Directions and Alternative Approaches. … Over the last 15 years, you have another overlay—the patient safety and quality movements.

4133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33756/psn-pdf
      October 01, 2013 - She is a national leader in the impact of radiologic testing on patient outcomes, and in the safety—particularly … Robert Wachter, Editor, AHRQ WebM&M: How did you get interested in the topic of safety in radiology? … RW: For some safety hazards, when things go wrong you see the results right away. … We should be leading efforts to increase its safety as opposed to trying to suppress those efforts or … This is what it means to be a radiologist now—it means we have to ensure the safety of what we do.

4134. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836976/psn-pdf
      April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022. … Compartment syndrome is a clinical diagnosis and patients’ reported symptoms are the earliest indicators … Approach to Improving Patient Safety Overall, this case demonstrates how an unstable pediatric patient … Ideally, two large bore peripheral IV lines should be placed in unstable patients. … The “3 As” is a useful to assess for compartment syndrome in pediatric patients.

4135. Duplicate Therapies in Retail Pharmacy | PSNet
      psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
      August 05, 2022 - Patients' memory for medical information. … safety concerns during the COVID-19 pandemic. … October 28, 2020 Patient safety education 20 years after the Institute of Medicine report … enhancing collaboration between community pharmacists and primary care providers to improve medication safety … The impact of electronic communication of medication discontinuation (CancelRx) on medication safety

4136. In Conversation With… Reed V. Tuckson, MD | PSNet
      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.

4137. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33701/psn-pdf
      October 01, 2010 - principles has led to two strikingly successful and widely discussed medical checklists: a surgical safety … A surgical safety checklist to reduce morbidity and mortality in a global population. … Surgical safety checklist: a redesign using human factors guidelines background to the surgical safety … University of Calgary, Canadian Patient Safety Institute, Calgary, Canada; 2009. 

4138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49726/psn-pdf
      March 01, 2015 - Wrong- patient surgery is a misidentification of the patient leading to a procedure performed on the … wrong patient. … safety experts would maintain that even one wrong-site surgery is too many. … the patient. … Wrong Patient A misidentification of the patient leading to a procedure performed on the wrong patient

4139. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49476/psn-pdf
      March 02, 2005 - As DVT prevention is one of the top safety priorities of the Agency for Healthcare Research and Quality … Orthopedic surgery patients are a special focus of most guidelines, since such patients are at extremely … safety issue, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened a Consensus … cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7978443 http://www.fda.gov/medwatch/SAFETY/1997/antico.htm … Actual image not from the patient in case presentation.

4140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865376/psn-pdf
      March 27, 2024 - The Commentary By Caitlin Loseth, MD The management of severely injured patients requires complex … Patients with cirrhosis exist in a delicate physiologic homeostasis where https://psnet.ahrq.gov//#4 … There was no mention of abdominal wall varices, but this is a common pitfall in operating on patients … When such patients are hypotensive at presentation, and progress to require CPR in the field or in the … CPR often needs to be paused in the setting of acute ATLS procedures in order to ensure safety.