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psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
January 01, 2009 - The literature is less clear on how those general preferences play out in different situations and patient … RW: Let's say a patient on your watch experienced a terrible medication error and was now in the ICU … Surveys tell us that patients want to hear about errors in their care, but these surveys do not necessarily … Nevertheless, many general recommendations have been elucidated; they tend to be based on survey data … : Evidence from survey data.
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - The hospitals elected to focus on the
use of PICCs following a survey that showed significant variation … For example, 47% of the respondents indicated that 10–25% of
PICCs inserted in their hospitals might … HMS has also focused on risk assessment
and therapies for patients at risk for venous thromboembolism … A cross-sectional
survey of vascular access practices in the ICU. … Morbidity & Mortality Rounds on the
Web: Case Studies. Patient Safety Network. December 1, 2012.
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - On the other hand, the treating physician might offer less information than explained to 'ordinary' patients … However, it might also have a negative effect on the physician–patient relationship. … Physicians who take on such patients must be educated about important issues in caring for other physicians … Doctors as patients: postal survey examining consultants and general practitioners adherence to guidelines … Self-reported health, illness, and self-care among finnish physicians: a national survey.
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - recipient has both heard the order correctly and transcribed it correctly.1 However, an ISMP member
survey … practice of recording and reading back verbal orders was not occurring as
often as desired – 45% of respondents … However, patients are often uncooperative and/or
violent or agitated, as illustrated here, precluding … For adult patients presenting with acute psychosis (from various causes), the most targeted emergency … Patients who are clearly psychotic are unlikely to respond to a benzodiazepine alone (e.g., midazolam
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - Who's on service today?" … Imagine if before I touch a patient, "Please wash your hands," flashes up on the screen of the glasses … colleagues observed 98 nurses while they prepared and administered a total of 4271 medications to 720 patients … Challenges in measuring the impact of interruption on patient safety and workflow outcomes. … Smith T, Darling E, Searles B. 2010 Survey on cell phone use while performing cardiopulmonary bypass.
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - know this patient was on this other medicine?” … because they have a record of what this patient is on. … Patients and families should have someone on their medical team whom they trust and count on to help … the community, and that access might make them more vulnerable to violence, as the ECRI Institute’s survey … on patients’ outcomes.
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - On interview, it was determined that the
patient did not have capacity to make complex medical decisions … Where a patient lacks capacity, any decisions taken on their behalf must
be in their best interests … – In a national survey of physicians from specialties “for which evidence-
based mind-body methods … – Only about half the respondents felt that “they received effective mentoring
during residency in … A questionnaire to measure general practitioners' attitudes to their role in the management of patients
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - The incorrect patient documentation on the EKG caused EKG results to be uploaded
to the wrong patients … Upon this physician’s review, an EKG had never been ordered on this
patient throughout her hospital … harm; the firm also noted that this number
was “drastically underreported”.1 Charting on Wrong Patient … who participated in a Kaiser Family Foundation survey had found an error in their electronic health … Fortunately, there were no adverse effects on any of the patients involved in the cases of mentioned
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - reduce overall costs by reducing ICU length of stay.(10) A patient on a ventilator riding a stationary … processes to promote physical activity and reduce sedation for patients on mechanical
ventilation, … Physical therapy utilization in intensive
care units: results from a national survey. … Managing the patient on mechanical ventilation in ICU: early mobility and
walking program. … When the patient achieves fair strength in the biceps (3/5 on exam), progress to exercise sessions
while
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - While the patient described in this case does not appear to have met criteria
for septic shock on her … On autopsy, the patient was found to have not only bilateral Streptococcus pyogenes and Klebsiella
pneumonia … With a fever and no crackles or wheezing on exam, the patient
described above would have had a PRS of … The current and future state of pediatric sepsis definitions: an
international survey. … The impact of cognitive and implicit bias on patient safety and quality.
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - through the system while keeping a balance on patient safety. … In the face of growing needs to get more surgical patients through busy systems while keeping patients … Finally, in phase 4, the whole team (referring and receiving) agrees on a patient plan and contingencies … Patterns of communication breakdowns resulting in injury to surgical patients. … Handoffs causing patient harm: a survey of medical and surgical house staff.
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - Theoretical impact of duty hour rules on patient safety
The duty hour rules were implemented with two … A policy that makes today's patients a bit safer at the cost of larger harm to patients later would not … Systematic review: effects of resident work hours on patient safety. … For example, if you think about just the issue of handoffs, the size and complexity of patients on medical … May 11, 2022
Barriers to accessing nighttime supervisors: a national survey of internal
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - Techniques for accessing a CVC vary based on the type of connector used. … effect on the clinician involved. … Evidence-based practice: improving outcomes for patients with a central venous access device. … National survey of central venous catheter flushing in the intensive care unit. … Managing the aftermath of critical incidents: meeting the needs of health-care providers and patients
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - education bundle to improve patient education and
engagement on VTE. … Survey staff on their attitudes and beliefs regarding VTE prophylaxis.
Define measures and goals. … Effect of real-time patient-centered education bundle on
administration of venous thromboembolism prevention … Data and Statistics on Venous Thromboembolism. … Effect of real-time patient-centered education bundle on
administration of venous thromboembolism prevention
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - She reportedly slipped while running on a wet floor. … The patient was crying and holding her left hip flexed with significant tenderness on examination, but … patient safety hazard. … For example, potassium supplements for a patient on furosemide is routine, however, this same drug may … Likelihood of reporting medication errors in hospitalized children: a survey of nurses and physicians
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - In a survey distributed to US hospitals about prevention of hospital–acquired urinary tract infections … In a survey of RNs working at 7 nursing homes, 52% did not know that routine irrigation of IUCs is contraindicated … a patient. … Urologic Patient. … opioid-free surgical patients.
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - Her research and academic interests focus on patient safety and quality improvement practices in the … Bettega provides data management support for Cal Long-term Care Compare, a website dedicated patients … Bohringer has a special interest in patient safety and he has authored papers on quality improvement … has expertise in developing logic models, tracking performance measures, and designing mixed methods surveys … Her editorial work has produced books and articles on topics including knowledge management, patient
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - No harm was done to the patient. … The laboratory is often unaware that the patient is pregnant. … Errors in laboratory medicine: practical lessons to improve patient safety. … Jt Comm J Qual Patient Saf. 2005;31:68-80. [go to PubMed] 7. … September 26, 2012
Leadership Survey: Immunization Against Burnout: Insights Report.
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Once the error was discovered, the patient was promptly started on cimetidine 300 mg IV daily, and her … each shift.( 3 ) A survey of community pharmacists confirms that they perceive environment and workload … studies reflect how many times pharmacists may have stopped the interacting combination from reaching patients … Related Resources From the Same Author(s)
Transition of care for hospitalized elderly patients—development … and visitor knowledge and confidence in reporting patient deterioration.
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psnet.ahrq.gov/web-mm/recurrent-appendicitis
January 15, 2020 - On physical examination, the patient showed rebound tenderness with guarding. … The patient was taken to the operating room (OR) for laparoscopic appendectomy. … In a study of more than 1500 such patients, only a tiny minority (0.2%) went on to develop clinical appendicitis … of appendicitis on both imaging and exploration. … January 23, 2017
Safety considerations in learning new procedures: a survey of surgeons