-
psnet.ahrq.gov/node/47671/psn-pdf
January 01, 2019 - Latino children experienced nearly twice the
rate of adverse events when compared with white children … Publicly insured children also had a higher
adverse event rate.
-
psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Because of a forcing function in the template,
he also had to enter a maintenance infusion rate in milliliters … He was unsure of the proper
infusion rate, so he arbitrarily chose 0.5 mL/hr. … The
night shift nurse continued the infusion at this rate, as did the nurse on the following day shift … require calculation of a weight-based loading dose,
maintenance dose, and calculation of infusion rate … If users program an infusion rate that
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#
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psnet.ahrq.gov/node/45330/psn-pdf
August 03, 2016 - Investigators found that hospitals with a greater aggregate rate of adverse events also had higher
readmission … www.ncbi.nlm.nih.gov/books/NBK20489/
https://psnet.ahrq.gov/issue/feasibility-preventable-readmission-rate-quality-measure
-
psnet.ahrq.gov/node/47497/psn-pdf
December 18, 2018 - For medical conditions, accredited hospitals had a lower readmission rate but no statistically
significant … difference in mortality rate.
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psnet.ahrq.gov/node/47008/psn-pdf
October 13, 2018 - In a sample of 2422 patients, the overall error rate decreased 20%. … At one hospital,
the error rate did not change because an increase in a specific insulin prescribing
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - For this patient, the success rate that should have been quoted during the informed consent process is … This success rate is still quite acceptable for many patients wishing to avoid surgery. … There was also no difference between the two groups with respect to subsequent intrauterine pregnancy rate … and repeat ectopic pregnancy rate. … No randomized prospective trials have compared fertility rate or recurrent ectopic rate after salpingectomy
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - 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 … , respiratory rate, blood pressure, SpO 2 , etc.) exceeds the "too high" or "too low" alarm limit settings … a highly publicized death at a well-known academic medical center.( 2 ) Despite repeated low heart rate … For example, if the hospital default setting for high heart rate is set at 130, but a certain patient
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Her vital signs were notable for a temperature of 38.6° C, heart rate of 115 beats
per minute, blood … pressure of 104/68 mm Hg, respiratory rate of 28 breaths per minute, and oxygen
saturation of 86% on … are diagnosed with sepsis, severe sepsis, or septic shock every year with an
associated mortality rate … Elements of SIRS include
abnormalities in temperature, heart rate, respiratory rate, white blood cell … 18 breaths per minute, heart rate of 104 beats per minute, and blood pressure 80/40 mm
Hg, the EMR
-
psnet.ahrq.gov/node/73106/psn-pdf
April 01, 2021 - Each blue point is the CLABSI rate measured each month. … Benchmarking is when a ward or hospital’s measure of quality, such as
the CLABSI rate per 1,000 central … this run chart, the external standard is the National Healthcare Safety Network (NHSN) mean CLABSI
rate … The run chart shows that this hospital’s CLABSI rate has been
consistently greater than the external
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psnet.ahrq.gov/node/47575/psn-pdf
December 19, 2018 - Communication-and-resolution programs had either a positive or neutral effect on all metrics including new
claims rate … , paid claims rate, and total liability costs.
-
psnet.ahrq.gov/node/43539/psn-pdf
March 26, 2015 - For example, the PSI for pressure ulcers demonstrated a high
false-negative rate, meaning that ICD-10 … PSIs demonstrated the opposite problem—potential for over-reporting due to a high false-
positive rate—and
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psnet.ahrq.gov/node/46296/psn-pdf
September 24, 2017 - operating
room personnel from survey data is associated with all-
cause 30-day postoperative death rate … Operating Room
Personnel From Survey Data Is Associated With All-cause 30-day Postoperative Death Rate
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - You can simply multiply out the intrinsic error rate for every step in the
process to figure out the … will decrease the error rate, for example, from a success rate of
96% all the way up to a success rate … It will decrease the error rate from 4% down to 1%. It'll have
improved it by 75%. … But in that 20-step process, I'm still at risk for a 1% error rate. … you will be guaranteed an irreducible error rate, no matter how you fix the systems
and processes.
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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - This rate translates to
over 1200 errors per year in a 500-bed hospital.(4) Since nurses often act as … For example, a pump that is programmed with an uncommonly high insulin infusion rate of 20
units per … alert requiring the nurse to confirm this dosage before permitting an override,
while an alert for a rate … In a large multicenter study
that included 24 hospitals, Barker found an administration error rate of … study found IV administration errors in 42% of doses; IV boluses that were
infused at an excessive rate
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - His heart rate was 44 beats per minute, which was felt to explain his symptoms. … Concerned about the patient’s heart rate slowing further, the ED physician ordered a syringe of atropine … bedside to be injected urgently if needed (atropine is given in emergent situations to raise the heart rate … *
*
Case: Near Miss (2)
The patient’s heart rate improved in the ED, and the plan was to discharge
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psnet.ahrq.gov/issue/finding-and-fixing-diagnosis-errors-can-triggers-help
January 31, 2024 - Download Citation
Related Resources From the Same Author(s)
Low rate … January 31, 2024
Do patients who read visit notes on the patient portal have a higher rate
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psnet.ahrq.gov/node/50689/psn-pdf
November 20, 2019 - Over the three-year study period, the
unadjusted CAUTI rate decreased slightly; unadjusted rates decreased … Over the three-year period, the unadjusted
MRSA rate decreased slightly from 0.075 to 0.071 cases per
-
psnet.ahrq.gov/issue/evaluation-feedback-modalities-and-preferences-regarding-feedback-decision-making-pediatric
September 08, 2021 - July 6, 2022
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department … August 5, 2015
The effects of resident level of training on the rate of pediatric prescription
-
psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - a preprogrammed dose of opioid when the
patient pushes a demand button with or without a constant-rate … and
transplant surgery
Prolonged surgery (> 2
hours)
Patient-controlled analgesia
(with basal rate … : drug concentration, initial loading dose, demand dose, lockout interval, and background infusion
rate … with
double-check by 2 RNs to verify
proper PCA connection and settings
for new administration, rate … Faces Pain Scale
Iowa Pain Thermometer
Oxygenation Pulse Oximetry (SpO2)
Ventilation
Respiratory Rate
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - definitions. 6 The criteria for defining opioid-induced respiratory depression can include respiratory rate … , and transplant surgery
Prolonged surgery (> 2 hours)
Patient-controlled analgesia (with basal rate … staff: drug concentration, initial loading dose, demand dose, lockout interval, and background infusion rate … In the case described, the patient was prescribed hydromorphone PCA without a continuous basal rate … Iowa Pain Thermometer
Oxygenation
Pulse Oximetry (SpO 2 )
Ventilation
Respiratory Rate