-
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
-
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
-
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
-
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
-
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//#references … References
1. Silveira MJ, Wiitala W, Piette J.
-
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
-
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
-
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.
-
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
-
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
-
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.
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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