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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - to call the agent for guidance instead of relying on
medical team to make a proxy decision
10
Significant … Not performing surgery would leave patient in significant pain; death might be the
patient’s preference … (4)
General Response to the Case
Significant Error 1: Opportunities for Improvement
Significant Error … 2: Opportunities for Improvement
Significant Error 2: Opportunities for Improvement (2)
POLST Paradigm … (polst.org)
Do Not Attempt Resuscitation – DN(A)R
Significant Error 3: Opportunities for Improvement
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psnet.ahrq.gov/node/34687/psn-pdf
February 10, 2011 - The costs of adverse drug events in hospitalized patients.
February 10, 2011
Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse
Drug Events Prevention Study Group. JAMA. 1997;277(4):307-11.
https://psnet.ahrq.gov/issue/costs-adverse-drug-events-hospitalized-patie…
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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - system has promise for advancing equitable health outcomes because the review of patient data shows no statistically … significant difference in response time and intervention, by race or ethnicity.
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - concluded that CO 2 insufflation may decrease the incidence of pain and bloating but the results were not statistically … significant. 15 The authors hypothesized that the difference in effect between children and adults … in children is a generally safe, medically necessary, and effective procedure but does carry risk of significant
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - If you have a system that allows anonymous reporting, it can snowball into some pretty significant toxic … Since MedStar's move in this direction, staff engagement scores have shown a statistically significant
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - between
allocating resources for zero harm initiatives and other areas of
healthcare, could be a significant … Statistically, patient harm is rare enough that reliably assessing
whether a harm is preventable or
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psnet.ahrq.gov/node/73106/psn-pdf
April 01, 2021 - Healthcare-associated infections such as CLABSI are an
important patient safety outcome and result in significant
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - In a study of 1958 surgical patients who refused transfusions due to religious reasons, there was a significant … The rates of in-hospital death or acute coronary syndrome were also not statistically significant between
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psnet.ahrq.gov/node/44305/psn-pdf
January 22, 2016 - National incidence of medication error in surgical patients
before and after Accreditation Council for Graduate
Medical Education duty-hour reform.
January 22, 2016
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients
Before and After Accreditation Council for Gra…
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psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
March 04, 2020 - missing this vital information places the patient at risk for withdrawal, which if untreated can lead to significant … One study found a significant increase in the ingestion of alcohol containing hand sanitizers between
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - maximal dose of an ACE inhibitor and 25 mg of spironolactone can have up to a 20% chance of experiencing significant … 1.7% of heart failure patients treated with spironolactone experienced hyperkalemia—an incidence not statistically
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - that specifically lead to patient harm), as well as adverse events (harms due to medical care), are significant … decreased from 12.6 per 1,000 preintervention to 5.2 per 1,000 postintervention (p=0.003). 4 There was no significant
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - size to attain
two ultimate research goals for the MPS: to determine whether the MPS has achieved a statistically … significant decrease in complications rates and to characterize procedural competence.
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psnet.ahrq.gov/node/44342/psn-pdf
November 03, 2015 - How effective are patient safety initiatives? A
retrospective patient record review study of changes to
patient safety over time.
November 3, 2015
Baines RJ, Langelaan M, de Bruijne M, et al. How effective are patient safety initiatives? A retrospective
patient record review study of changes to patient safety over…
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - SS : They found a significant reduction in urinary catheterization rates, but not a significant reduction … We know that a small but significant percentage of patients will have bacteriuria, and they'll be completely … to be largely preventable based on Pronovost's study from a couple of years ago showing a 66% and statistically … significant reduction in infection in a large number of intensive care units in Michigan.
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psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
June 15, 2024 - Healthcare-associated infections such as CLABSI are an important patient safety outcome and result in significant
-
psnet.ahrq.gov/node/866992/psn-pdf
May 29, 2024 - defined as a pattern of behaviors in which patients continue to use a substance
despite experiencing significant … the tests are accurate,19 and PWUS have a very favorable opinion of
them,20,21 which has promoted significant … continues to evolve, there are several key areas where research and policy
development can have a significant … classified as drug paraphernalia,
preventing the establishment of sanctioned SSPs.24 On the federal level, significant
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - of those cases involved wrong patient procedures.( 3 ) This small number almost certainly reflects significant … These deaths are particularly disturbing since “a significant number...are attributable to misidentification … Reassuringly, a recent study from same group found that continuous monitoring resulted in significant … Such technology, combined with Web-based electronic medical records and wireless computing, offers significant
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - 10 of those cases involved wrong
patient procedures.(3) This small number almost certainly reflects significant … These deaths are particularly
disturbing since “a significant number...are attributable to misidentification … Reassuringly, a recent study from same group found that continuous monitoring resulted in significant … Such technology, combined with Web-based electronic medical records and wireless
computing, offers significant
-
psnet.ahrq.gov/issue/risk-medication-errors-and-nurses-quality-sleep-national-cross-sectional-web-survey-study
February 09, 2022 - Based on survey data of a sample of nurses, the authors identified a significant association between