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psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - For verbal communication with patients, it is important to limit
the quantity of information that patients … case highlights the importance of pursuing
innovative approaches that can enhance the quality and safety … critically important
aspect of patient care, which has significant implications for patient outcomes … Interventions to improve care for patients with limited health literacy. … Closing the loop: physician communication with diabetic
patients who have low health literacy.
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - are admitted to the hospital
Describe a guideline-recommended insulin regimen for a hospitalized patient … The patient had previously had a stroke. … The hospitalist caring for the patient consulted an
endocrinologist to help with the glucose management … safety improvement staff, lab, dietary and nutrition services, and hospital administration. … Enhancing insulin-use safety in hospitals: practical
recommendations from an ASHP Foundation expert
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psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
September 20, 2011 - The patient was asymptomatic and other vital signs were stable. … The patient had several more short runs of non-sustained ventricular tachycardia (NSVT). … Though the patient survived the initial arrest, she remained hypotensive and unfortunately did not regain … In the case described above, a patient who underwent percutaneous coronary intervention developed a brief … safety.
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - The nurse gave the patient pain medication. … among bedside nurses about how to
https://psnet.ahrq.gov/web-mm/chest-tube-complications
monitor patients … At that point, some would remove the chest tube and monitor
the patient. … references
recommends a few hours of clamping followed by chest radiography when there is doubt about the safety … data and
recommends a clamp trial if there is any doubt whether an air leak has sealed (or for all patients
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - The safety issue raised by this case is not limited to EHRs: how to insure that information specified … Electronic alerts to prevent venous thromboembolism among hospitalized patients. … safety issues. … Safety
December 1, 2010
Antibiotic shortages in pediatrics. … , 2012
Electronic alerts to prevent venous thromboembolism among hospitalized patients
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - that diagnostic errors remain a prevalent ‘blind spot’ in patient safety and contribute to poor patient … October 30, 2024
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … Safety Innovations
Remote Response Team and Customized Alert Settings Help Improve … 31, 2023
Annual Perspective
Improving Diagnostic Safety … and Quality
April 26, 2023
Patient Safety Innovations
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Patient eligibility for in-home hospital care is assessed in the health care setting;
eligible patients … Features of the program include:
Patient eligibility and consent: Patients who present in an emergency … The cost per patient day was 32percent
lower for Hospital at Home patients than for hospital inpatients … , COPD, or asthma) found that the cost per patient day was 38 percent lower for
Hospital at Home patients … Safety Focus
The Hospital at Home program provides inpatient-level care to patients in their homes
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psnet.ahrq.gov/node/866370/psn-pdf
July 31, 2024 - safety when anesthetizing
patients with significant cardiopulmonary disease. … Awareness under anesthesia is more common in young patients taking medications for seizures or patients … Approaches to Improving Patient Safety
https://psnet.ahrq.gov//#19
https://psnet.ahrq.gov//#20
https … patients
to prevent awareness. … Christian Bohringer, MBBS
Consulting Editor, AHRQ's Patient Safety Network (PSNet)
Professor of Anesthesiology
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psnet.ahrq.gov/node/49486/psn-pdf
August 21, 2005 - safety.(2)
Pharmacology of Warfarin
First, warfarin acts by inhibiting the action of vitamin K, which … To summarize, in the elderly patient in this case, when we initiate warfarin therapy we should expect … Clinical Rules for Initial Dosing of Warfarin
Among hospitalized patients, particularly elderly patients … WARFDOCs was developed as part of
an AHRQ-funded patient-safety project. … The patient developed an acute episode of bleeding that required
transfusion.
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - The Commentary Diagnostic errors have gained recent visibility as a patient safety and public health … Diagnostic errors—the next frontier for patient safety. JAMA. 2009;301:1060-1062. … The nature of adverse events in hospitalized patients. … October 28, 2020
COVID-19: the dark side and the sunny side for patient safety. … March 24, 2021
Patient centred diagnosis: sharing diagnostic decisions with patients
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - Delirium poses several risks to the patient. … , too busy to see patient, etc.)? … Additionally, family may be willing to participate in the care of the patient, which may reduce patient … Elements of the hospital environment can contribute to delirium and expose patients to safety risk. … May 8, 2017
Patient safety and quality outcomes for ED patients admitted to alternative
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - The
x-ray was clearly labeled as belonging to the patient. … and
belonged to this other patient who already had surgery. … Examples of such defenses include training
programs; safety protocols, policies, and procedures; and … in not examining the
patient and her x-rays. … Many defenses
failed to protect this patient.
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psnet.ahrq.gov/web-mm/crossing-borderline
June 01, 2022 - The patient had a history of suicide attempts, including episodes of self-inflicted trauma and abusive … Later that evening at home, the patient set herself on fire, prompting immediate return to the hospital … The priority treatment goal that characterizes the early phase of psychotherapy is to help the patient … Patients with BPD frequently demonstrate mood shifts, and this patient, in the structured setting of … safety simulation curriculum for residents and fellows.
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - The patient was breathing spontaneously. … Safety
Avoid noxious stimulation of the patient before the depth of anesthesia is adequate
This patient … care area where patients are likely to develop
laryngospasm. … Incidence and associated factors of laryngospasm among
pediatric patients who underwent surgery under … Office-based anesthesia: safety and outcomes in pediatric
dental patients.
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psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - This means that identifying patients
that require emergent or urgent intervention is key. … with abdominal pain; this is particularly true in patients with obesity. … The knowledge gained from such an analysis
can be used to improve patient safety. … Health Policy, Quality and Informatics Program Center for Innovations in
Quality, Effectiveness, and Safety … Effect of emergency department crowding on outcomes of admitted
patients.
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psnet.ahrq.gov/node/851555/psn-pdf
July 31, 2023 - The
patient had no “chief complaint,” but admitted on “review of systems” to constipation for several … Three days later, the patient was admitted to a second hospital with perforated bowel and sepsis. … to chronic opioid use in 20% of these patients, but can also be idiopathic in nature.5 All
patients … Management
The management of stercoral colitis depends on the clinical status of the patient. … Barnes, MD, FACEP
Consulting Editor, AHRQ, Patient Safety Network (PSNet)
Health Science Clinical Professor
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - The patient was taken to the operating room for drainage of the
abscess. … A severe, circumscribed tenderness is a frequent
early finding for patients developing early SEA. … Patients suspected of having spinal epidural abscess should be referred for timely imaging. … Spinal epidural abscess: a meta-analysis of 915 patients.
Neurosurg Rev. 2000;23:175-204. … Advances in Patient Safety: From
Research to Implementation, Vol 2.
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psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - Review some common errors in the care of adolescent patients and strategies to prevent them. … Education
about diet, exercise, and glucose monitoring should begin at diagnosis for all patients and … Although metformin and insulin are the only medications for T2DM approved in the United
States for patients … The challenge for all providers who care for adolescent patients is to consider
prevalent issues of … , within the limits of state law and patient safety;
normalization of the topic as a routine component
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Innovation Patient Safety Focus
The SASH program personalized care coordination services successfully … and stakeholders to identify ways that providers of affordable housing could support the
health and safety … Older Americans 2010: Key indicators of Well-
Being. December 2010.
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psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - Discuss patient safety risks of anticoagulation. … for
adverse drug events.(6,7) The patient described in this case was fortunate in that his INR, though … For the case patient, who was chronically taking
warfarin, the medical team could have scheduled an … Though the case patient may not have been a good candidate
for self-monitoring given his dementia, a … For many patients, however, including the patient in this case, the new anticoagulants will
present