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Showing results for "surveys on patient safety culture".
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4201. Anemia and Delayed Colon Cancer Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
      July 21, 2020 - The choice of test of course depends on the rate of bleeding, patient characteristics, and the degree … Although this patient was on anticoagulation, he should have undergone further testing to evaluate for … Being on anticoagulation does not reduce the importance of evaluating a patient with iron deficiency … June 26, 2019 Patient and visitor aggression in healthcare: a survey exploring organisational … safety culture and team efficacy.

4202. The Role of Bar Coding and Smart Pumps in Safety | PSNet
      psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
      September 01, 2008 - defense in detecting patient deterioration and protecting patients by recovering errors caused by other … Survey investigates role of pharmacy in technology use in hospitals [press release]. … Poon's research has focused on using health information technology to improve patient safety. … to have time to actually work on this technology to make sure that we don't expose our patients to any … I would say based on our experience that there seems to be a pretty good case, both in terms of patient

4203. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
      January 01, 2024 - Immediately after the operation, the surgeon informed the patient and instructed him to lie flat on his … On postoperative day (POD) 6, the patient reported clear drainage from the surgical site. … On POD 25, the wound appeared to have dehisced, and the patient was readmitted to the hospital for advanced … pain. 6 6 Case Details (3) On POD 42, the patient was readmitted and diagnosed after magnetic resonance … Spinal Dural Repair: A Canadian Questionnaire. Global Spine Journal. 2018;8(4):359-364.

4204. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
      January 01, 2024 - pediatric sepsis. • Identify tools to assist the clinician in recognizing sepsis in the pediatric patient … – With a fever and no crackles or wheezing on exam, the patient described above would have had a PRS … of 3 on initial presentation, rising to a 4 on her second ED visit, indicating a moderate risk of pneumonia … The Current and Future State of Pediatric Sepsis Definitions: An International Survey. … The Impact of Cognitive and Implicit Bias on Patient Safety and Quality.

4205. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet
      psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
      February 26, 2025 - Many patients prefer a trial of nonoperative management when it is an option, but these patients must … , depending on social factors and underlying disease processes. … There can be a large gap in care coordination when patients are readmitted, particularly if patients … Impact of radiotherapy on surgical repair and outcome in patients with rectourethral fistula. … Results of a choice experiment survey.

4206. Retained Surgical Items: Definition and Epidemiology. | PSNet
      psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
      September 15, 2024 - They do not contain radiopaque markers, are not to be placed inside patients, and are not counted. … Implant Systems Instrumentation and individual components arranged on multiple preset trays that are … Obesity may be a risk factor specifically among patients who have an abdominopelvic operation . … Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey … on United States operating rooms.

4207. Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet
      psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
      September 27, 2023 - 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 … ASHP Guidelines on Preventing Medication Errors in Hospitals.

4208. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
      October 01, 2007 - Effects of sleep inertia on cognition. … , or not answering patients’ questions Shanafelt TD, et al. … and On-Call Systems When demands for care are nearly constant Limited “on-duty” shifts with mandatory … home with return to duty if needed Intermediate patient needs Longer “on-duty” shifts, during which … , telephone operators, and other team members The National Board of Medical Examiners is testing a survey

4209. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49737/psn-pdf
      June 01, 2015 - 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. … products in male and female patients with urinary incontinence.

4210. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
      psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
      March 09, 2022 - Immediately after the operation, the surgeon informed the patient and instructed him to lie flat on his … On postoperative day (POD) 6, the patient reported clear drainage from the surgical site. … On POD 22, at a subsequent clinic follow-up, the patient reported intermittent chills, continued drainage … On POD 42, the patient was readmitted and diagnosed after magnetic resonance imaging (MRI) with discitis … Spinal Dural Repair: A Canadian Questionnaire.

4211. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49588/psn-pdf
      August 01, 2009 - There was only one patient care assistant scheduled on this weekend shift. … The practicing nurse needs to focus on the care of patients. … caring for more critically ill patients, the same nurse "volunteered" to admit the new patient. … Rather than using the bedpan, the patient insisted on getting up and going to the bathroom. … Administer annual nurse satisfaction survey such as NDNQI to measure and assess if staffing plan is

4212. The Role of Graduate Medical Education (GME) in Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
      February 01, 2010 - The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study. … Transfers of patient care between house staff on internal medicine wards: a national survey. … residents but also on their patients. … In the resident questionnaire, we ask questions beyond duty hours. … What we find is that statistically if we see duty hours violations in a program on the resident questionnaire

4213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846564/psn-pdf
      March 29, 2023 - CDS provides clinicians, patients, and other individuals with relevant data (e.g. patient-specific information … Despite respondents giving the tool high usability ratings and reporting that the CDS was valuable, … Here we limit the discussion to several patient-safety-focused resources posted on PSNet in 2022.   … For CDS specifically, more focus is needed on patient-centered CDS (PC CDS), which supports patient-centered … their impact on patient safety will be needed, especially in relation to new technological approaches

4214. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - 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 … a 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

4215. In Conversation With… Richard Kronick, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
      February 01, 2014 - It's been nearly 15 years since the IOM's initial report on patient safety galvanized the movement. … The Guide to Patient and Family Engagement in Hospital Quality and Safety focuses on four primary strategies … For example, efforts such as the Partnership for Patients Program are dependent on the evidence that … 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.

4216. Diagnostic Delay in the Emergency Department | PSNet
      psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
      September 18, 2024 - diagnostic errors.( 3,11 ) Other methods of identifying or estimating diagnostic errors include autopsies, surveys … the available evidence, regardless of patient harm.( 16 ) This definition helps identify, on a retrospective … National Hospital Ambulatory Medical Care Survey: 2013 Emergency Department Summary Tables. … Effect of emergency department crowding on outcomes of admitted patients. … Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.

4217. EMR Entry Error: Not So Benign | PSNet
      psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
      July 01, 2012 - On physical examination, in addition to abnormal pulmonary findings, the patient had multiple flat purple … She noted the results and went to see other patients. … medical records (EMRs) and their impact on patient safety. … Systems that harmonized on Monday might be incommunicado on Wednesday. … October 13, 2018 A national survey assessing the number of records allowed open in electronic

4218. Updates in the Management of High-Risk Pulmonary Embolism | PSNet
      psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
      December 02, 2020 - One survey of 113 PE specialists found that the most common approach was to continue heparin throughout … Case and Commentary—Part 4 The patient received a bed on the stepdown unit several hours later. … He was intubated emergently and the code team discovered that the patient had never continued on a heparin … Pulmonary embolism response teams, in addition to advising on initial management, help manage patients … Treatment of submassive and massive pulmonary embolism: a clinical practice survey from the second annual

4219. In Conversation with…Eric G. Poon, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
      September 01, 2008 - Poon's research has focused on using health information technology to improve patient safety. … to have time to actually work on this technology to make sure that we don't expose our patients to any … I would say based on our experience that there seems to be a pretty good case, both in terms of patient … defense in detecting patient deterioration and protecting patients by recovering errors caused by other … Survey investigates role of pharmacy in technology use in hospitals [press release].

4220. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
      June 14, 2023 - They have wonderful resources available on their website that teach patients and families, and patient … shows that partnering with families and patients results in better patient outcomes, especially on emotional … Patient and family engagement: a survey of US hospital practices. … June 14, 2019 Fidelity and the impact of patient safety huddles on teamwork and safety … culture: an evaluation of the Huddle Up for Safer Healthcare (HUSH) project.