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Showing results for "surveys on patient safety culture".
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4201. Amended Lab Results: Communication Slip | PSNet
      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.

4202. Psn-Pdf (pdf file)
      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

4203. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
      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

4204. Dangerous Dapsone | PSNet
      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.

4205. "Recurrent" Appendicitis | PSNet
      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

4206. Editorial Team | PSNet
      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

4207. 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.

4208. Are Residency Duty Hour Rules Improving Patient Safety? | PSNet
      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

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. 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.

4211. 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

4212. 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.

4213. 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.

4214. 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.

4215. 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.

4216. 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

4217. 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.

4218. 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

4219. 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.

4220. 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.