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psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - Care Medicine and the Society of Critical Care Medicine.( 6 ) The guidelines recommend careful planning … factor for errors and adverse events.( 12 ) Moreover, handover within and between units can result in critical … team; (ii) assessment of the patient after transport to determine any deterioration in condition; (iii … Warren J, Fromm Jr RE, Orr RA, Rotello LC, Mathilda HM; American College of Critical Care Medicine. … To Err Is Human: Building a Safer Health System.
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - patient was
assigned an American Society of Anesthesiologists physical status classification of level III … has led to under-reporting of medication errors and relatively little
attention being paid to this critical … psnet.ahrq.gov/issue/institute-safe-medication-practices
https://psnet.ahrq.gov/issue/err-human-building-safer-health-system … setting presents unique challenges and obstacles compared to
other hospital settings due to its time-critical … The Critical Care Safety Study: The incidence and
nature of adverse events and serious medical errors
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - https://psnet.ahrq.gov//#ref2
https://psnet.ahrq.gov//#ref3
emergency departments (EDs) and pediatric critical … usability and efficacy trials, such
evaluations should not be limited to academic medical settings; (iii … Medication error reporting in rural critical access
hospitals in the North Dakota Telepharmacy Project … Lewis TL, Wyatt JC. mHealth and mobile medical apps: a framework to assess risk and promote safer
use
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - of what they've accomplished and to make themselves
available to other members for consultation; (iii … as the basis for motivating action and directing
decision-making about how to pursue improvement is critical … Prior research has shown that, particularly where many actions would be
beneficial, it is critical not … To Err Is Human: Building a Safer Health System.Washington,
DC: Committee on Quality of Health Care
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Maintaining equipment and supplies in "ready" status is critical for systems responsiveness. … Making health care safer: a critical analysis of patient safety practices. … June 1, 2019
Perspective
Making Healthcare Safer … III Report
March 30, 2020
Testing an intervention to improve health care worker
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psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
May 28, 2020 - We’ve also been advancing innovation to spur the development of safer medical devices. … irreversibly debilitating conditions, as well as a new program that we are establishing called the Safer … program, devices that don’t meet all the criteria to be considered a “breakthrough,” but otherwise may be safer … This can provide us with critical information more quickly and more efficiently. … Class III: Devices that “sustain or support life, are implanted, or present potential high risk of illness
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psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - Class III: Devices that “sustain or support life, are implanted, or present potential high risk of illness … We’ve also been advancing innovation to spur the development of safer medical devices. … irreversibly debilitating conditions, as well as a new program that we are establishing called the Safer … program, devices that don’t meet all the criteria to be considered a “breakthrough,” but otherwise may be safer … This can provide us with critical information more quickly and more efficiently.
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - trainees to critically examine what they see every day on rounds and at the bedside, we can
make patients safer … Before attempting to define situational awareness for any type of clinical practice, it is first critical … understand what it is about a situation that the physician must be aware of.(6) In fact, even more critical … Reiff DA, Shoultz T, Griffin RL, Taylor B, Rue LW III.
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical … The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. … the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical … Book/Report
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety … infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - dose into the desired interval for administration (in the described case, three times daily), and (iii … providers continue to adopt EHRs with CPOE, they should consider strongly implementing automated CDS at the critical … software that can accurately convert this message into a standard data format (often HL7 standard), and (iii … Computerized physician order entry and medication errors in a pediatric critical care unit. … June 14, 2017
Electronic prescribing in pediatrics: toward safer and more effective medication
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Since critical care units have an entirely different level
of acuity, their practice competencies are … In this case, a
nurse with primary roles in non-critical care—by his own admission not qualified to … work in critical
care—floated to a unit where he lacked necessary competencies. … using a root cause analysis (RCA),
(ii) disclosure to the patient and family with an apology, and (iii … To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press;
2000.
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - utilized); (ii) improper decision to use the line, despite inability to withdraw blood from it; and
(iii … Error #1
Best practice for CVC placement mandates the use of ultrasound as a critical element for safety … Adequate
supervision and the use of simulators are critical adjuncts to proper procedural training. … Real-time ultrasound-guided subclavian vein cannulation
versus the landmark method in critical care … Making Health Care Safer: a Critical Analysis of Patient Safety Practices: Summary.
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - ); (ii) development and implementation of service-oriented clinical decision support (CDS) ( 7 ); (iii … Toward that end, we developed the Office of the National Coordinator–approved SAFER (System Assurance … ii) incorrect or incomplete use of EHR technology by those within the health care organization; and (iii … SAFER Guides. … It's easy in retrospect to be critical, it was too much money, it was too fast, it was too x , it was
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - decrease in surgical morbidity and annual mortality; (ii) a reduction in hospital-acquired conditions; (iii … Critical role of the surgeon–anesthesiologist relationship for patient safety. … Medical team training improves team performance:
AOA critical issues. … Safer paediatric surgical teams: a 5-year evaluation
of crew resource management implementation and … Such understanding is conveyed by repeating critical parts of the
message.
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - trainees to critically examine what they see every day on rounds and at the bedside, we can make patients safer … Before attempting to define situational awareness for any type of clinical practice, it is first critical … understand what it is about a situation that the physician must be aware of.( 6 ) In fact, even more critical … Reiff DA, Shoultz T, Griffin RL, Taylor B, Rue LW III.
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psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
September 01, 2017 - We wish everybody would look at our SAFER guides , which we commissioned and worked with nationally … It's easy in retrospect to be critical, it was too much money, it was too fast, it was too x , it was … ); (ii) development and implementation of service-oriented clinical decision support (CDS) ( 7 ); (iii … ii) incorrect or incomplete use of EHR technology by those within the health care organization; and (iii … SAFER Guides.
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - However, some experts argue that a safer approach is to clamp the chest tube and monitor
closely for … Lekshmi Santhosh, MD Clinical Fellow Division of Pulmonary and Critical Care Medicine Department of … Courtney Broaddus, MD Professor Division of Pulmonary and Critical Care Medicine Department of
Medicine … Millikan JS, Moore EE, Steiner E, Aragon GE, Van Way CW III.
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - utilized); (ii) improper decision to use the line, despite inability to withdraw blood from it; and (iii … Error #1 Best practice for CVC placement mandates the use of ultrasound as a critical element for … Adequate supervision and the use of simulators are critical adjuncts to proper procedural training. … Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients … Making Health Care Safer: a Critical Analysis of Patient Safety Practices: Summary.
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - Starting therapy in an elderly patient with a single agent is generally a safer
strategy, and many patients … the
geriatric patient, (ii) the importance of anticipating confusion from sound-alike medications, (iii … indication.(10) Explaining that some pills
contain multiple pharmacotherapeutic agents must be considered a critical … To Err is Human: Building a Safer Health System.
Washington, DC: National Academy Press; 2000.
3.
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psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - Since critical care units have an entirely different level of acuity, their practice competencies are … in critical care—floated to a unit where he lacked necessary competencies. … using a root cause analysis (RCA), (ii) disclosure to the patient and family with an apology, and (iii … That he did not object to a critical care assignment or seek support should raise questions regarding … To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.