-
psnet.ahrq.gov/node/37042/psn-pdf
March 04, 2011 - higher risk of
mortality from conditions requiring emergency treatment and may experience a higher rate … This finding corroborates another recent study, which also found a lower rate of invasive
procedure
-
psnet.ahrq.gov/node/35424/psn-pdf
April 09, 2013 - clinical-impact-and-frequency-anatomic-pathology-errors-cancer-diagnoses
This AHRQ-funded study estimated a 12% error rate … this study builds on that literature by
employing a method that is not limited by the overall low rate
-
psnet.ahrq.gov/node/34641/psn-pdf
March 03, 2011 - study-deaths-associated-anesthesia-and-surgery-based-study-599-548-
anesthesias-ten
Published in 1954, this article examines the death rate … There was one anesthesia death for every 1,560
patients, a death rate of 0.06%.
-
psnet.ahrq.gov/node/40807/psn-pdf
September 01, 2016 - hospital in Spain that had an established CPOE system, this study found an
overall administration error rate … with CPOE in a closed-loop system
has been shown to significantly reduce the overall medication error rate
-
psnet.ahrq.gov/node/44951/psn-pdf
March 02, 2016 - The rate
of defective handoffs declined significantly after implementation of the tool. … approximately 12% of examined handoffs were defective,
highlighting the challenge of achieving a zero error rate
-
psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - His initial vital signs showed a blood pressure of 130/75 mm hg, heart rate of 65 beats per minute, respiratory … rate of 16 breaths per minute, temperature of 36.3°C, and an oxygen saturation of 90% on room air. … >90 beats per min Respiratory rate >20 breaths per min or PaCO2 <32 mm Hg WBC <4,000/μL or >12,000/μL … ratio) Neurologic (GCS) 0–24 ≥ 2 MEWS (Modified Early Warning Score) Systolic blood pressure Heart rate … Dysfunction System score) 6 organ systems: Neurologic (GCS) Cardiologic (heart rate, systolic blood
-
psnet.ahrq.gov/node/41283/psn-pdf
April 11, 2012 - Review of autopsy case series over the past half century demonstrates a persistently high
rate of clinically … Of note, in this series, 30.3% of patients who died underwent autopsy, a
rate that is much higher than
-
psnet.ahrq.gov/node/35868/psn-pdf
July 10, 2008 - AHRQ-supported study analyzed information from nearly 3 million operations between 1985 and 2004,
discovering a rate … authors suggest that the average large hospital may be involved in such an event every 5 to
10 years, a rate
-
psnet.ahrq.gov/node/45328/psn-pdf
July 27, 2018 - observational cohort study found that patients with abnormal vital signs—temperature, blood pressure,
heart rate … , respiratory rate, and oxygen saturation—upon hospital discharge were more likely to be
readmitted
-
psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - and transplant
surgery
• Prolonged surgery (> 2 hours)
• Patient-controlled analgesia (with
basal rate … with double-
check by 2 RNs to verify proper PCA
connection and settings for new
administration, rate … – Drug concentration
– Initial loading dose
– Demand dose
– Lockout interval
– Background infusion rate … opioid PCA should be monitored
closely
25
Monitoring Component Assessment Type
Vital Signs Heart Rate … Faces Pain Scale
Iowa Pain Thermometer
Oxygenation Pulse Oximetry (SpO2)
Ventilation Respiratory Rate
-
psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - His initial vital signs showed a blood pressure of 130/75 mm hg, heart rate of 65 beats per
minute, … respiratory rate of 16 breaths per minute, temperature of 36.3°C, and an oxygen saturation of 90%
on … >90 beats per
min Respiratory rate >20 breaths per min or PaCO2 <32
mm Hg WBC <4,000/? … (quick
Sequential Organ
Failure Assessment
score)
Systolic blood pressure <90 mm Hg Respiratory rate … 2
MEWS (Modified
Early Warning Score)
Systolic blood pressure Heart rate Respiratory rate
Temperature
-
psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - including a Best Practice Alert in the electronic health record (EHR), greatly increased the screening rate … to identify early AAA, and decreased the rate of failure to recognize and follow up diagnosed AAA. … This and other system improvements reduced the number and rate of AAA ruptures (average of 1.03/100,000 … outlined in the 2015 National Academy of Medicine report, 1 there is an urgent need to decrease the rate … After implementation of these system improvements, the number and rate of AAA rupture has decreased (
-
psnet.ahrq.gov/node/45957/psn-pdf
August 15, 2018 - As measured by a composite
score, the complication rate did not differ between trainees and attending … There was no
difference in the rate of follow-up imaging, length of stay, or duration of antibiotics
-
psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - The fetal heart rate (FHR) at presentation was category 2, described as moderate
variability with normal … blood pressure around 90 mm Hg, mean arterial pressure (MAP) 60-70, pulse 110-120/min,
respiratory rate … vital signs showed
a blood pressure of 88/40, mean arterial pressure of 57, pulse 142/min, respiratory rate … in the United States; 60% of these deaths are considered
preventable.1 The U.S. has an increasing rate … ) and a false-positive rate of 4%.
-
psnet.ahrq.gov/node/43773/psn-pdf
May 01, 2015 - Result in 1.3 Million
Fewer Patient Harms: Interim Update on 2013 Annual
Hospital-Acquired Condition Rate … Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly
demonstrates
-
psnet.ahrq.gov/node/46074/psn-pdf
December 22, 2017 - When medications were dispensed from original
packaging, the medication administration error rate was … When multicompartment devices were used,
the medication administration error rate was 3%.
-
psnet.ahrq.gov/node/46904/psn-pdf
August 20, 2018 - The overall mortality rate in the study was less than 0.2%. … The authors
suggest that this unexpectedly low mortality rate may have made it difficult to detect differences
-
psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - The most common cause of false asystole alarms is under-counting of heart rate due to failure of the … Similar to the
case described here, under-counting of heart rate due to low-voltage QRS complexes led … change in cardiac rhythm; parameter violation alarms that detect when a vital sign measurement
(heart rate … , respiratory rate, blood pressure, SpO2, etc.) exceeds the "too high" or "too low" alarm limit
settings … For example, if the hospital default setting for high heart rate is
set at 130, but a certain patient
-
psnet.ahrq.gov/node/44447/psn-pdf
September 02, 2015 - hospital-acquired sepsis, which together accounted for about one-third of cases, had
a higher mortality rate … readmissions following severe sepsis and found substantial variation
in readmission rates, with an overall rate
-
psnet.ahrq.gov/node/39523/psn-pdf
September 26, 2016 - alarming finding was that administration
without interruptions still generated a procedural failure rate … of nearly 70% and a clinical error rate of 25%.