- 
                                        
psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - had not been prescribed the drug during the hospital stay, and the last patch had been placed more than … The BPMH is more comprehensive than a routine medication history and involves two steps: (i) a systematic … going through the motions" when completing a routine medication history at transitions of care, but rather … These criteria most commonly include older patients, polypharmacy, and/or having more than three comorbid
                                     
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - unique feature of palliative care is that the harmful consequences from errors may be harder to identify than … Considering that hydromorphone is 7 times more potent than morphine, the starting dose for hydromorphone … Generally, opioids are rather safe drugs. … 24 ) 
 Take-Home Points 
 
 Errors are prevalent in palliative care, but may be harder to identify than
                                     
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psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
April 29, 2020 - and as high as 88% in others 1  (although the published case series are small, most involving less than … ruling out respiratory viruses, and the nursing staff were focused on preventing viral transmission, rather … than conducting routine skin assessments. … Given the rarity of Fournier’s Gangrene and its lower prevalence among women than among men, this complication
                                     
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - explain to the patient how a diagnosis so widespread and worrisome could have been delayed for more than … new palpable breast mass in a 60-year-old woman should be considered “suspicious,” certainly more so than … describes as “WYSIATI” – what you see is all there is. 20  We assume that what is reported is all there is, rather … than searching for missing information or additional guidance.
                                     
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - altered mental status, therapies such as atropine or transcutaneous pacing should be initiated. 1  Rather … than following the algorithm, focus was instead diverted to the patient’s neurologic symptoms and ACLS … Use of a treadmill may be safer than having the patient walk up three flights of steps, as stairwells … 14, 2009 
 
 
 
 
 
 
 
 
 
 
 
 
 
 WebM&M Cases 
 
 
 
 
 
 
 
 
 
 Are Two Insulin Pumps Better Than
                                     
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psnet.ahrq.gov/node/33730/psn-pdf
June 01, 2012 - It was around that time
that the term patient safety began to be used in the UK other than in terms … It's had some adverse consequences because there is an
enormous amount of rather disorganized regulation … There's another form of reporting, which is rather different from this voluntary reporting system, the … You spend a
little less than 10%. … This is a rather crude response, and it's very hard still to make an
argument to senior managers and
                                     
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - depth of anesthesia. 4  Unintended episodes of awareness are therefore related to anesthesia management rather … than the operation or surgeon. … suffers awareness and feels severe pain while unable to move, the psychological effects may be worse than … physically active patients Young patients who are physically fit often require higher anesthetic dosing than … special precaution with intravenous anesthesia Propofol infusions carry a greater risk of awareness than
                                     
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Charles Johnson
Pregnancy and birth are normal physiologic processes that optimally require support rather … than medical
intervention. … cesarean birth, and future potentially life-threatening placental abnormalities are
greater for cesarean than … Additionally, more than half of rural US counties
do not have hospital-based obstetric services, significantly … cardiac-conditions-in-obstetric-care/
ACOG defines hemorrhage as a cumulative blood loss of greater than
                                     
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - The lesion excised was the one referred to as "left inferior orbit" rather than "left cheek"—an error
                                     
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - issues is often perceived to be a fundamental aspect of the patient's care and the domain of nursing rather … than medical staff.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - helpful in this Case because the
resuscitation event experienced by the team occurred while in a hallway rather … than in a clinical area such
as the surgical suite. 
                                     
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - discussing Artistotle, once wrote, "We do not act rightly because we have virtue or excellence,
but we rather … from the patient perspective.(10) However, in other studies, immersive experiences performed better than
                                     
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psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Most institutions send written instructions to the patient regarding the bowel preparation (rather than
                                     
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - the county health care system generally to see if the public hospitals had a lower standard of care than … Rather, it was a problem with the nurses, who ignored the patients and who were pre-charting and post-charting … It may be more than a 1-day story, but at least you won't be accused of not being up-front. … It is a challenge, but there are plenty of people who study this and have more expertise than we do as … One of the final tallies that the county provided indicated that more than 600 of the hospital's 2400
                                     
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - Electronic health record reviews likely have a lower rate of missing data than the paper chart reviews … The rate of adverse events in outpatient settings was, therefore, lower than researchers found in inpatient … Three factors enabled the breakthrough that reduced CLABSI rates by more than 80%. … It is just a more complex problem than hospital-acquired infections. … I would rather see us focus on a smaller number of metrics and report to fewer organizations.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - unlikely that a patient being cared for by residents at Harvard or UCSF at 2:00 AM is in more peril than … Rather, it was a problem with the nurses, who ignored the patients and who were pre-charting and post-charting … It may be more than a 1-day story, but at least you won't be accused of not being up-front. … It is a challenge, but there are plenty of people who study this and have more expertise than we do as … One of the final tallies that the county provided indicated that more than 600 of the hospital's 2400
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - "( 28 ) In fact the vision laid out by the e-Patient prime mover, Tom Ferguson, went much deeper than … Yet in many ways it is much less change than we would wish. … More than once I was called into a production manager's office and was schooled about how it is vital … can view the record at home, that will bring the clinical encounter into the greater sphere of life rather … than having it be something that only happens at that place down the road.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - We have very good guidelines about what to do in terms of prevention, yet the rates are still higher than … It is just a more complex problem than hospital-acquired infections. … I would rather see us focus on a smaller number of metrics and report to fewer organizations. … Electronic health record reviews likely have a lower rate of missing data than the paper chart reviews … Three factors enabled the breakthrough that reduced CLABSI rates by more than 80%.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - , the history of quality and safety in the National Health Service (NHS) until recently has been a "rather … Rather, they concerned incompetent or poorly performing doctors, whose colleagues were covering up for … you expected and what has been harder than you expected? … In the UK, when you're trying to introduce change, you rather feel that you're in a goldfish bowl. … RW:  What's been harder than you thought?
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - Rather, they concerned incompetent or poorly performing doctors, whose colleagues were covering up for … you expected and what has been harder than you expected? … In the UK, when you're trying to introduce change, you rather feel that you're in a goldfish bowl. … RW:  What's been harder than you thought? … , the history of quality and safety in the National Health Service (NHS) until recently has been a "rather