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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
    June 01, 2013 - mortality of about 15% The mortality is even higher in older patients (as in this case) See Notes for references … facilities and seniority of surgeons and anesthesiologists involved in high risk cases See Notes for references … of basic care processes is associated with increased adverse events and patient harm See Notes for references … cycles have been used to improve ward and admission care for emergency surgical patients See Notes for references … proportion of difference between the best performing and worst performing hospitals See Notes for references
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
    March 01, 2012 - common—nearly 20% of hospitalized older Medicare patients will be readmitted within 30 days See Notes for references … Timely follow-up appointments Home visits Postdischarge phone calls (as in this case) See Notes for references … Readmissions can negatively affect the patient, the family, and the health care system See Notes for references … filling prescriptions Other issues with medication management New or worsening symptoms See Notes for references … this, they are generally recommended to help in the transition from hospital to home See Notes for references
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49418/psn-pdf
    October 01, 2003 - (d) Hold the tube in a glass of https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references water; do bubbles appear indicating exhaled breath? … Associate Dean for Graduate Medical Education University of Nebraska Medical Center College of Medicine References … View AHRQ Disclaimers https://psnet.ahrq.gov//#references http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
  4. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - delirium during hospitalization Dementia cannot be diagnosed if delirium is present See Notes for references … confine patients to bed, with attendant risks Loss of sleep due to noise or intrusions See Notes for references … Reduce external stimuli  may exacerbate delirium May exacerbate hyperactive behavior See Notes for references … See Notes for references. Inouye SK, Charpentier PA. … Assessment Method Diagnosis of delirium requires features 1 and 2, and either 3 or 4 See Notes for references
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49762/psn-pdf
    June 01, 2016 - patient's documentation of prior preferences lies with the accepting physician, https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references and that physician will be … identified "point person" to ensure they are incorporated into the medical https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#referencesReferences 1. Silveira MJ, Wiitala W, Piette J.
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - survival to discharge less than 10% In-hospital SCA survival estimated at 18% See Notes for complete references … delivered for non-shockable rhythms Long pauses in CPR before shock delivery See Notes for complete references … immediately function as a team with others with whom they have not rehearsed See Notes for complete references … defibrillator receive training in the specific device(s) they are going to use See Notes for complete references … errors in high-use locations such as Emergency Departments and Critical Care See Notes for complete references
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
    July 01, 2012 - teaching hospitals, many of these procedures are performed by unsupervised trainees See Notes for references … in Central venous catheter insertion Thoracentesis Lumbar puncture Paracentesis See Notes for references … instead of experience, is a more useful predictor of high reliability and safe systems See Notes for references … bronchoscopy, laparoscopic cholecystectomy, advanced cardiac life support, and colonoscopy See Notes for references … skills, retention of skills, patient care, and outcomes, while reducing hospital costs See Notes for references
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49541/psn-pdf
    August 21, 2007 - https://psnet.ahrq.gov/web-mm/mark-my-tooth https://psnet.ahrq.gov//#figure https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references Data from the Oral and Maxillofacial Surgeons National Insurance … https://psnet.ahrq.gov//#references Recommendations for Safe Practice In order to improve the quality … https://psnet.ahrq.gov//#references Use a "time out" immediately prior to beginning the procedure to … Smith, DDS Clinical Professor Emeritus University of California, San Francisco References 1.
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49511/psn-pdf
    May 01, 2006 - disease states (renal failure, as indicated by serum creatinine value) when https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references Polycitra is electronically ordered. … https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references Robert J. … Pharmacy and Therapeutics Executive Director of Pharmacy University of Pittsburgh Medical Center References
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
    October 01, 2008 - access may develop enhanced expectations for timely and accurate delivery of information See Notes for references … Computer and Internet access for medically underserved populations has been expanding See Notes for references … supported by health promoters In both examples, the patient manages privacy and security See Notes for references … national experience with personal health records, will stimulate further innovation See Notes for references
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49744/psn-pdf
    October 01, 2015 - The rationale for meaningful use was https://psnet.ahrq.gov//#references simple: policymakers were … Given the https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov … //#references https://psnet.ahrq.gov//#table https://psnet.ahrq.gov//#references clinical decision … https://psnet.ahrq.gov//#references The technical challenges won't be solved until or unless we all … References 1. Excerpts from the American Recovery and Reinvestment Act of 2009.
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49598/psn-pdf
    February 01, 2010 - https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references In this case, the preoperative … communication among caregivers and patients, the incidence and http://www.drugid.info https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#figure https://psnet.ahrq.gov//#figure … Pittsburgh School of Pharmacy Executive Director of Pharmacy University of Pittsburgh Medical Center References
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49766/psn-pdf
    August 21, 2016 - per year.(4) https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away https://psnet.ahrq.gov//#references … https://psnet.ahrq.gov//#references In this case, the delayed communication surrounded the diagnosis … https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references To address the above problems … Professor of Hospital Medicine, UCSF Physician Lead for Inpatient Informatics, UCSF Medical Center References
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
    April 01, 2013 - metabolic homeostasis (e.g., hyper- or hypoglycemia, fluid and electrolyte problems) See Notes for references … evidence or generally accepted practices) are available from national organizations See Notes for references … safe PN practice guidelines Unfortunately, adherence to these guidelines has been poor See Notes for references … providers and may require less clarification or intervention compared with written orders See Notes for references … formulations, but these may not be safer in the absence of a standardized PN-use process See Notes for references
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
    July 01, 2011 - measurements of Internationalized Normalized Ratio (INR) and adjustments in the warfarin dose See Notes for references … checked every 28 days but one week was appropriate in light of recent hospitalization See Notes for references … improve INR control Standardized, patient-centered approaches seem to be more effective See Notes for references … than warfarin, but may be cost effective because there is no INR testing and monitoring See Notes for references
  16. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
    October 01, 2011 - setting of acute illness but key to minimize impact of hospital-acquired deconditioning See Notes for references … Contraindications for exercising ICU patients Termination thresholds for activity See Notes for references … support) At risk for complications preventable with early exercise and activity * See Notes for references … ventilator setting for increase in positive end-expiratory pressure or assist control mode * See Notes for references
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
    December 01, 2011 - 100% of hospitalists and most emergency physicians use iPads in direct clinical care See Notes for references … communication among health care teams through use of video, pictures, text messaging, or email See Notes for references … providers Allow for bedside decision support which helps clinicians provide optimal care See Notes for references … (PHI) May also increase interruptions, which may be associated with medical errors See Notes for references
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - name=fiverights https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#table https://psnet.ahrq.gov … //#references each other (as they did in this case) and combine with the active failure of individuals … Hedy Cohen, RN, BSN, MS Vice President Institute for Safe Medication Practices References 1. … View AHRQ Disclaimers http://www.ismp.org/Tools/AssessERR.pdf https://psnet.ahrq.gov//#references https … ://psnet.ahrq.gov//#references https://www.ahrq.gov/policy/electronic/disclaimers/index.html
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
    February 01, 2010 - The trends are likely explained by higher caloric intake and lower physical activity See Notes for references … disproportionately affected—T2DM comprises 46%–86% of all new cases of diabetes in minority youth See Notes for references … recommendations, sexual histories in adolescents are sometimes inappropriately omitted See Notes for references … mothers are less likely to receive prenatal care and more likely to deliver prematurely See Notes for references … fold The analysis estimated that 45% of pregnant teens have a history of sexual abuse See Notes for references
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - considered mistakes This data relies on self-reporting and likely underestimates magnitude See Notes for References … shame may be long-lasting Feelings appear to occur regardless of stage of training See Notes for References … emotions Do not avoid the patient Avoid defensive medical practice Accept responsibility See Notes for References … rather than a sign of weakness Disclose error to patient and apologize if appropriate See Notes for References … opportunity for professional role-modeling of error acknowledgment and open discussion See Notes for References

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