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Informed or Misled? | PSNet

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April 24, 2018 - latter may not provide all the information a patient wants but recognizes that information concerning specific … Regarding the specific type of anesthesia, the anesthetist should also inform the patient that several … More specific information (possibly in written form) concerning risks and complications should be provided … Operator-specific risks could be quoted if they are available. … Consideration should be given to providing patient-specific risks, according to coexistent pathology.

Medication/Drug Errors | PSNet

psnet.ahrq.gov/curated-library/medicationdrug-errors

March 12, 2021 - not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific … resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific … Reports discussing the results are segmented into specific areas of focus such as health care-associated … health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific

Patient safety and telephone medicine: some lessons from closed claim case review. | PSNet

psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review

May 18, 2022 - telephone-related closed malpractice claims from a large insurance company database in order to elucidate specific

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records. | PSNet

psnet.ahrq.gov/issue/mortality-risks-associated-emergency-admissions-during-weekends-and-public-holidays-analysis

September 02, 2020 - Unlike prior studies of the weekend effect, this study included multiple specific markers of patients

Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. | PSNet

psnet.ahrq.gov/issue/through-patients-eyes-understanding-and-promoting-patient-centered-care

October 04, 2006 - members of the clinical team," and offering “culturally sensitive educational materials tailored to specific

Low literacy impairs comprehension of prescription drug warning labels. | PSNet

psnet.ahrq.gov/issue/low-literacy-impairs-comprehension-prescription-drug-warning-labels

January 21, 2009 - Patients at an urban primary care clinic underwent structured interviews to address their understanding of specific

Health IT Patient Safety Action and Surveillance Plan. | PSNet

psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan

December 18, 2013 - recommendations of the Institute of Medicine report , Health IT and Patient Safety , the plan includes specific

The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units. | PSNet

psnet.ahrq.gov/issue/safety-organizing-scale-development-and-validation-behavioral-measure-safety-culture-hospital

December 16, 2011 - Research and Quality (AHRQ) recommends that hospitals monitor the culture of safety to assess their specific

Identification and Prioritization of Health IT Patient Safety Measures. | PSNet

psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures

September 29, 2017 - committee proposes to hold health IT vendors, health care organizations, and clinicians accountable for specific

Perspective: a culture of respect—part 1 and part 2. | PSNet

psnet.ahrq.gov/issue/perspective-culture-respect-part-1-and-part-2

October 04, 2006 - discusses the role a culture of respect plays in developing high-reliability organizations and identifies specific

Medical Problem Solving: An Analysis of Clinical Reasoning. | PSNet

psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning

July 18, 2018 - relevance for those interested in patient safety and quality improvement is that competence may be problem specific

Surgical Site Infections | PSNet

psnet.ahrq.gov/primer/surgical-site-infections

December 15, 2024 - for SSI include patient factors (such as age, tobacco use, diabetes, and malnutrition) and procedure-specific … safety assessment and improve teamwork and communication in surgical care, and also generally include specific … interventions may be an important part of overall institutional approaches to preventing SSIs, but the specific

Triggers and Trigger Tools | PSNet

psnet.ahrq.gov/primer/triggers-and-trigger-tools

September 15, 2024 - Well-defined, specific triggers like this also lend themselves to automated electronic detection, making … Refinement of this methodology has led to the development of more specific triggers. … It combines blunt triggers (such as rapid response team activation) with more specific but relatively

Getting the Diagnosis Both Right and Wrong | PSNet

psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong

May 29, 2024 - The term "cognitive bias" is often used to describe a heuristic that, when applied in a specific situation … Diagnosis often occurs as a coproductive activity between persons in specific ecosystems, and the interactions … of nonanalytic, pattern recognition decision-making but instead aim to consider common pitfalls in specific … While there are not yet specific evidence-based strategies to support such a suggestion, one could imagine … However, there is also a risk that team members may be overly deferential to a specific person due to

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet

psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care

February 26, 2025 - risk for adverse events after discharge : BOOST uses the 8Ps Risk Assessment to screen patients for specific … risk factors known to be associated with adverse post-discharge events, initiate risk-specific interventions … In 2013 , the Society of Hospital Medicine released Pedi-BOOST, which incorporated unique pediatric-specific … that includes stakeholders from various disciplines; and establishing team rules, general goals, and specific … Set appropriate project goals: Goals should be “SMART” (specific, measurable, achievable, realistic,

Spotlight

psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx

January 01, 2025 - Laboratory test results were also similar except that the hemoglobin was even higher as was the urine specific … The accuracy of CT for diagnosing the cause of abdominal pain depends on the location of pain and the specific … For example, the authors of a 2008 meta-analysis found CT to be 91% sensitive and 90% specific for diagnosing … Although the patient’s bilirubin was mildly elevated, this is a non-specific finding and could have represented … However, diagnostic radiographs are only 69% sensitive and 57% specific.7 Imaging in High-Risk Abdominal

Thin Air | PSNet

psnet.ahrq.gov/web-mm/thin-air

March 01, 2006 - Case Objectives Identify the gas-specific non-interchangeable connectors used for bulk gas supply … Although the flowmeter itself may be physically designed to insert into only its specific gas port (see … A gas-specific non-interchangeable fitting for low-pressure oxygen tubing would be possible to produce … A physical arrangement that precludes doing the wrong thing, like the gas-specific non-interchangeable … What are potential specific solutions to the problem of mismatched adapters on flowmeters?

What Does Simulation Add to Teamwork Training? | PSNet

psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training

October 01, 2004 - situations that link directly to their previous work experience; Provides scenarios of known and specific … The advantages of this approach are as follows: It allows concentration on specific skills and knowledge … for each specific crew, including material that may be of little relevance to other crews; It targets … It can be most effective when a specific group of individuals actually do work together as a dedicated … fidelity of a simulation activity is more related to the overall conduct of the scenario than to the specific

In Conversation with David W. Bates about Are We Safer Today? | PSNet

psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today

February 26, 2025 - They look for specific things that suggest someone may have had an adverse event. … that people follow certain approaches in specific settings. … The keys there were developing checklists or bundles for specific types of important infections. … They are relatively simple and used in very specific situations. … David Bates: Change packages are sets of tools that enable an institution to take up a specific practice

Are We Safer Today? | PSNet

psnet.ahrq.gov/perspective/are-we-safer-today