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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - , 2024
Patient Safety Primers
Retained Surgical Items
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - healthcare workers noted an overall
downward shift in the results of surveys of patient safety culture and items … The NSC also developed supplemental resources, including the
Self-Assessment Tool and an Implementation
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - The patient was transferred from the PACU to the surgical floor at 20:00 where
supplemental oxygen was … For patients also
receiving supplemental oxygen, APSF recommends continuous SpO2 and ETCO2.31
A 2012 … desaturation, bradypnea, or hypoventilation (SpO2 < 93% or RR < 12 bpm or ETCO2 >
45 mmHg)
Use of supplemental … However,
the need for supplemental O2 was a potential indicator that continuous SpO2 and end tidal CO2 … Continuous capnography should be used in all patients receiving supplemental O2.
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - The patient was transferred from the PACU to the surgical floor at 20:00 where supplemental oxygen was … For patients also receiving supplemental oxygen, APSF recommends continuous SpO 2 and ETCO 2 . 31 … desaturation, bradypnea, or hypoventilation (SpO2 < 93% or RR < 12 bpm or ETCO2 > 45 mmHg)
Use of supplemental … However, the need for supplemental O 2 was a potential indicator that continuous SpO 2 and end tidal … Continuous capnography should be used in all patients receiving supplemental O 2 .
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - national performance measures from CMS, the Leapfrog Hospital Survey , and information from other supplemental … Cooperation and Development has adapted 6 of AHRQ’s PSIs, including measures of retained surgical items
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - The patient was admitted overnight for observation and discharged
the next day after treatment with supplemental … ”
– They can prompt team members to remind each other of delegated tasks and
action items to ensure
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - 30 national performance measures from CMS, the
Leapfrog Hospital Survey, and information from other supplemental … Cooperation and Development has adapted 6 of AHRQ’s PSIs, including measures of retained surgical
items
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - The patient was admitted
overnight for observation and discharged the next day after treatment with supplemental … They can prompt team members to remind each other of delegated tasks and action items
to ensure follow-through
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - and compile a list of all prescribed medicines, over the counter medicines, supplements
and herbal items … Relying on the trained health coach to inventory these
items is more effective than relying on a list … duplication of ingredients is taking place, where ingredients are working
against one another, or items
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - the patient was found to be somnolent and hypoxemic, with
oxygen saturation around 80%, requiring supplemental … receiver (S).21 In this case, implementing a
standardized handoff tool may have helped resurface action items
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - The patient was admitted overnight for observation and discharged the next day after treatment with supplemental … They can prompt team members to remind each other of delegated tasks and action items to ensure follow-through
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psnet.ahrq.gov/primer/simulation-training
September 15, 2024 - , 2024
Patient Safety Primers
Retained Surgical Items
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - and compile a list of all prescribed medicines, over the counter medicines, supplements and herbal items … Relying on the trained health coach to inventory these items is more effective than relying on a list … hidden duplication of ingredients is taking place, where ingredients are working against one another, or items
-
psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2
Test
April 28, 2021
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
The Case
A full-term pregnant patient was admitted in March 2…
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - , the patient was found to be somnolent and hypoxemic, with oxygen saturation around 80%, requiring supplemental … receiver (S). 21 In this case, implementing a standardized handoff tool may have helped resurface action items
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Supplemental oxygen
and nitroglycerin paste resulted in resolution of the patient's symptoms, but she
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Supplemental oxygen and nitroglycerin paste resulted in resolution of the patient's symptoms, but she
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - Medical equipment supply stores are likely to have additional items such as mechanical lifts, large wheelchairs
-
psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Medical equipment supply stores are likely to have additional items such as mechanical lifts, large
-
psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Perform a Contributory Factor Analysis using a checklist of items (see Table 2).
4.