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psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - ensure that robust and accurate transmission of e-prescribing data and workflow processes are the rule rather … than the exception. … e-prescribing system, a provider might select "minocycline tablet, 100 mg" that is considerably more expensive than
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psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - experience “mood swings” of emotional disruption and acting out behavior for briefer periods of time than … , Hamilton Depression Inventory, PHQ-9) can help to attribute mood symptoms to depressive disorder, rather … than to the associated borderline personality disorder.
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - When she could not be contacted the first day by phone, a letter should have been sent then, rather than … Obtain or verify contact information, preferably including more than one contact method, each time a
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - able to:
• Describe how health care providers should evaluate acute neurological
deficits of less than … hospital in this case had a stroke neurology team, so the
decision to obtain non-acute MRI/MRA imaging rather … than acute CT
angiography and perfusion imaging suggests a diagnostic error (unless
additional information
-
psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - Objectives
Describe how health care providers should evaluate acute neurological deficits of less than … hospital in this case had a stroke neurology team, so the decision to obtain non-
acute MRI/MRA imaging rather … than acute CT angiography and perfusion imaging suggests a diagnostic
error (unless additional information
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - workflow which are punctuated by pages, texts, and calls have vastly increased and are more frequent than … America that state that a new fever in a patient in the ICU “should trigger a careful clinical assessment rather … than automatic orders for laboratory or radiologic tests.” 9 The reflexive ordering of tests without
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - "Sepsis-3") redefined sepsis
as infection leading to organ dysfunction and suggested using greater than … been helpful in identifying the type of shock as cardiogenic
resulting from myocardial infarction rather … than sepsis.
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - education: we often consider a patient’s presentation as a problem to be solved at one point in time, rather … than a recurring and evolving problem that is influenced by ongoing changes in a patient’s health. … effect: the patient lost a significant amount of weight, although the rate of weight loss was more than
-
psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - The proper triage of trauma patients includes you over-calling so that
you're sensitive more than specific … they thought might be going on, and then
made the decision to transport them towards a local facility rather … than the tertiary care facility that is
defined for this disease process.
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - and complexities in oral anticoagulation with warfarin (Coumadin) and may be easier and safer to use than … abdominal surgery is at high risk, and guidelines suggest starting prophylaxis for such patients.(20) Rather … than just thinking about "starting packs," we should also consider "starting lacks" that might have
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - This process should last no longer than a few minutes and normally takes place in the form of a brief … unclear etiology, possible aspiration vs. community-acquired pneumonia vs. pulmonary embolism, etc.") rather … than labeling the patient with a definitive diagnosis (e.g., aspiration pneumonia).
-
psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - Learning Objectives Describe how health care providers should evaluate acute neurological deficits of less than … hospital in this case had a stroke neurology team, so t he decision to obtain non-acute MRI/MRA imaging rather … than acute CT angiography and perfusion imaging suggests a diagnostic error (unless additional information
-
psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - The current NQF portfolio includes more than 600 measures, and there will be more coming forward. … looked at the NQF portfolio (which at that time numbered about 150 measures or so, and we now have more than … For the first time, there was awareness that our payment policies have to be modified, even more than … characteristic of NQF's role in promoting safe practices is that the organization does not develop measures; rather
-
psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - The metabolic panel was
normal except for borderline elevation of serum creatinine, higher than his … “High-risk” abdominal pain is
characterized by clinical features including age greater than 65 years … while also improving resource utilization and
decreasing costs to the health system.23 In this case, rather … than discharging the patient with a
questionable diagnosis and unresolved pain, the clinician could
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - concentration for sodium chloride was mistakenly entered as 77 mEq/100 mL, a ten-fold higher concentration than … Rather, the safety process often relied on a dietician to notify the team if the TPN had not been ordered … order sets should be standardized to include a uniform bag size of 250 mL for patients who weigh less than … or equal to 10 kg and 500 mL for patients who weigh greater than 10 kg.
-
psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - Culture change is more important and impactful to patient safety than any one TeamSTEPPS tool or strategy … to gain insights on the ways healthcare professionals may treat patients as who you do things to rather … than who you do things with . … Hines: I think that today, there is a broader recognition of what constitutes patient safety issues than … The core curriculum has shifted to a less hospital-centric approach than previous iterations of TeamSTEPPS
-
psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - The core curriculum has shifted to a less hospital-centric approach than previous iterations of TeamSTEPPS … Culture change is more important and impactful to patient safety than any one TeamSTEPPS tool or strategy … to gain insights on the ways healthcare professionals may treat patients as who you do things to rather … than who you do things with . … Hines: I think that today, there is a broader recognition of what constitutes patient safety issues than
-
psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - Identify factors than can make someone a vulnerable patient in the context of healthcare; discuss possible … Elucidating and documenting specific patient goals like going home to enjoy loud music rather than relying … If clinicians are task saturated and burned out, spending progressively more energy on the EHR, than … needs for that diagnosis. 22 The ability of a hospital to get the patient discharged in less time than … Now more than ever, as the demands on healthcare workers reach new peaks and continue to change day-to-day
-
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - decision support should suggest alternatives that
do not involve cutting tablets into portions other than … but this approach is
not designed to be used to convert patients from one opioid to
another, but rather … – Methadone's peak respiratory depressant effects typically occur later, and
persist longer, than … 5 mcg/hr patch is the initial buprenorphine dose for patients who
are opioid-naïve or taking less than … The patch is not
recommended for patients on more than 80 OME per day.
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - The nurse informed him that the patient had developed a junctional rhythm with a heart rate less than … been given 100 mg of metoprolol XL and 180 mg of diltiazem CR by the hospital admitting physician, rather … than the 50 mg of metoprolol XL and no diltiazem intended by her outpatient cardiologist. … flag to medication and problem lists indicating that the patient has been seen in clinic more recently than … of clinical information, it is important not to abandon the safety practices used in the past, but rather