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Total Results: 173 records

Showing results for "pressure injury chart audit tools".

1. The Forgotten Turn | PSNet
   psnet.ahrq.gov/web-mm/forgotten-turn
   August 01, 2018 - injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, … These tools are well described in a recent guideline on pressure ulcer prevention.( 9 ) Multiple known … At our last random audit, we found no pressure ulcers in 32 hip fracture patients cared for during a … facility, to identify these patients, staff members place a SKIN ALERT sticker on the outside of the chart … Guidelines for the prevention of pressure ulcers. Wound Repair Regen. 2008;16:151-168. 

2. How often do physicians review medication charts on ward rounds? | PSNet
   psnet.ahrq.gov/issue/how-often-do-physicians-review-medication-charts-ward-rounds
   September 23, 2020 - How often do physicians review medication charts on ward rounds? … and their rate of chart review decreased as the number of patients seen increased. … How often do physicians review medication charts on ward rounds? … July 26, 2017 Root cause analysis for hospital-acquired pressure injury. … January 22, 2014 Audit of missed or delayed antimicrobial drugs.

3. Missing the Point—Eye Injury | PSNet
   psnet.ahrq.gov/web-mm/missing-point-eye-injury
   March 01, 2005 - protection, and both globe and intracranial injury are therefore common concomitant injuries. … Failure to obtain an accurate visual acuity using a Snellen chart (standard eye chart used in most physician … Clinicians may be tempted to not formally test visual acuity as it can be difficult to locate the eye chart … Although intraocular pressure might be lowered in penetrating globe injury, ocular pressure assessment … Lacerations and wounds involving the eyelid must be carefully evaluated for possible globe and intracranial

4. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
   psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
   November 27, 2019 - The combination of a supraphysiologic blood pressure target and the patient’s altered blood pressure … ’s spinal cord injury. … June 9, 2010 Surgical robot examined in injuries. … November 13, 2013 Audit of missed or delayed antimicrobial drugs. … June 27, 2012 Sponges, tools and more left inside Washington hospital patients.

5. Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety. | PSNet
   psnet.ahrq.gov/issue/follow-markedly-elevated-serum-potassium-results-ambulatory-setting-implications-patient
   March 01, 2018 - March 27, 2005 Simulation and the diagnostic process: a pilot study of trauma and rapid … July 29, 2020 Assessing patients 2019 experiences with medical injury reconciliation … July 10, 2013 Dirty surgical tools put patients at risk. … May 20, 2020 Impact of time pressure on dentists' diagnostic performance. … December 10, 2014 Detection of missed injuries in a pediatric trauma center with the

6. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. | PSNet
   psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial
   December 01, 2010 - A WebM&M commentary discussed a case involving a fall resulting in injury. … December 7, 2005 The 5th National Audit Project (NAP5) on accidental awareness during … November 12, 2014 5th National Audit Project (NAP5) on accidental awareness during general … July 20, 2016 Towards international consensus on patient harm: perspectives on pressure … injury policy.

7. "Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs. | PSNet
   psnet.ahrq.gov/issue/anybody-list-youre-more-worried-about-qualitative-analysis-exploring-functions-questions
   September 16, 2015 - Learning from lawsuits: using malpractice claims data to develop care transitions planning tools … August 24, 2022 The 5th National Audit Project (NAP5) on accidental awareness during … November 12, 2014 5th National Audit Project (NAP5) on accidental awareness during general … Patient Safety Innovations The e-Autopsy/e-Biopsy: A Systematic Chart … March 9, 2016 Does time pressure have a negative effect on diagnostic accuracy?

8. Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis. | PSNet
   psnet.ahrq.gov/issue/health-care-workers-experiences-workplace-incidents-posed-risk-patient-and-worker-injury
   June 23, 2021 - communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit … discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … diagnoses and radiation exposure in patients with blunt multiple trauma. … February 1, 2023 Barriers and facilitators to reporting medical device-related pressure

9. Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. | PSNet
   psnet.ahrq.gov/issue/exploring-role-salient-distracting-clinical-features-emergence-diagnostic-errors-and
   October 06, 2010 - March 23, 2016 Does time pressure have a negative effect on diagnostic accuracy? … 2021 Factors underlying suboptimal diagnostic performance in physicians under time pressure … March 18, 2020 Effect on diagnostic accuracy of cognitive reasoning tools for the workplace … Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart … March 20, 2013 Accuracy of pediatric trauma field triage: a systematic review.

10. Nurses' use of computerized clinical guidelines to improve patient safety in hospitals. | PSNet
    psnet.ahrq.gov/issue/nurses-use-computerized-clinical-guidelines-improve-patient-safety-hospitals
    June 06, 2018 - November 29, 2023 Trauma Resuscitation Using in situ Simulation Team Training (TRUST) … March 8, 2017 The "physician-led chart audit": engaging providers in fortifying a culture … November 8, 2006 Patterns of errors contributing to trauma mortality: lessons learned … injuries and medication administration errors: an integrative review. … August 21, 2019 Root cause analysis for hospital-acquired pressure injury.

11. Tracking progress in patient safety: an elusive target. | PSNet
    psnet.ahrq.gov/issue/tracking-progress-patient-safety-elusive-target
    May 25, 2011 - February 17, 2010 Triangulating case-finding tools for patient safety surveillance: a … February 29, 2012 Do nurse and patient injuries share common antecedents? … April 15, 2005 Targeted chart review of pediatric patient safety events identified by … Are evidence-based practices associated with effective prevention of hospital-acquired pressure … See More About The Topic Health Care Providers Health Care Executives and Administrators Audit

12. Medication reconciliation at hospital discharge: a qualitative exploration of acute care nurses' perceptions of their roles and responsibilities. | PSNet
    psnet.ahrq.gov/issue/medication-reconciliation-hospital-discharge-qualitative-exploration-acute-care-nurses
    October 20, 2021 - February 24, 2021 Clinical and economic impacts of explicit tools detecting prescribing … October 13, 2021 Nursing bedside clinical handover—an integrated review of issues and tools … May 19, 2021 Intervention study for the reduction of medication errors in elderly trauma … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

13. Cognitive testing of older clinicians prior to recredentialing. | PSNet
    psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
    January 08, 2020 - February 15, 2017 Association of low-dose whole-body computed tomography with missed injury … diagnoses and radiation exposure in patients with blunt multiple trauma. … intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood pressure … discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart … June 2, 2021 Application of electronic trigger tools to identify targets for improving

14. Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis. | PSNet
    psnet.ahrq.gov/issue/analysis-readmissions-mobile-integrated-health-transitional-care-program-using-root-cause
    April 13, 2022 - After one year in operation, MIH-CP performed a chart review to determine causes of readmission among … November 24, 2021 A quality improvement initiative using peer audit and feedback to improve … injury incidence. … injuries. … September 15, 2021 Root cause analysis for hospital-acquired pressure injury.

15. Haste Makes Care Unsafe | PSNet
    psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    March 27, 2005 - Accordingly, development and implementation of communication tools may be needed to help prevent the … The purpose of communication tools as cognitive aids in such circumstances is to help prevent human errors … While it is tempting to look at a case like this and focus only on understaffing or production pressures … Patient Safety Innovations The e-Autopsy/e-Biopsy: A Systematic Chart … May 11, 2022 Five-year audit of adherence to an anaesthesia pre-induction checklist.

16. Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association. | PSNet
    psnet.ahrq.gov/issue/analysis-deaths-related-anesthesia-period-1996-2004-closed-claims-registered-danish-patient
    July 27, 2005 - discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart … August 22, 2018 A novel process audit for standardized perioperative handoff protocols … May 30, 2012 Association of hospital participation in a regional trauma quality improvement … March 23, 2016 Does time pressure have a negative effect on diagnostic accuracy? … injuries.

17. An innovative collaborative model of care for undiagnosed complex medical conditions. | PSNet
    psnet.ahrq.gov/issue/innovative-collaborative-model-care-undiagnosed-complex-medical-conditions
    September 13, 2017 - August 23, 2023 Success in hospital-acquired pressure ulcer prevention: a tale in two … September 28, 2005 Differences in the reporting of care-related patient injuries to existing … January 5, 2011 Is there a benefit to multidisciplinary rounds in an open trauma intensive … audit. … March 5, 2014 The "physician-led chart audit": engaging providers in fortifying a culture

18. Between a rock and a hard place: disclosing medical errors. | PSNet
    psnet.ahrq.gov/issue/between-rock-and-hard-place-disclosing-medical-errors
    October 19, 2022 - November 12, 2014 5th National Audit Project (NAP5) on accidental awareness during general … mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma … Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … injuries. … June 23, 2021 Implementing a human factors approach to RCA(2) : tools, processes and

19. Implementation strategies in the context of medication reconciliation: a qualitative study. | PSNet
    psnet.ahrq.gov/issue/implementation-strategies-context-medication-reconciliation-qualitative-study
    August 05, 2020 - strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools … (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and … discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

20. Medication error identification rates by pharmacy, medical, and nursing students. | PSNet
    psnet.ahrq.gov/issue/medication-error-identification-rates-pharmacy-medical-and-nursing-students
    October 31, 2018 - October 31, 2018 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … March 8, 2017 A cluster randomized trial of two implementation strategies to deliver audit … February 26, 2014 The contribution of prescription chart design and familiarity to prescribing … August 30, 2023 The diagnostic and triage accuracy of digital and online symptom checker tools