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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - injury with
subsequent abscess of his right knee and osteomyelitis of the distal femur requiring bone … Education of
the patient is very important and is provided by the infusion company. … Home administration of
medication requires the visual ability and hand-eye coordination to connect and … saline or dextrose before and after administration of the medication. … OPAT has been successfully utilized by health systems since the 1970s.
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Thus, a
proper RCA includes an assessment of the environment (e.g., time of day, staffing levels, lighting … a
regular assessment of medication doses, drug interactions, or key error prevention and patient safety … steps
(e.g., daily assessment of the need for continued venous or urinary catheterization).(12) Additionally … Effects of computerized physician order entry and clinical decision
support systems on medication safety … simulation
Medium
Supervision of trainees
No routine assessment of
knowledge/understanding
Medium
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - and/or date of birth, the pharmacy staff required only a last name from the
patient. … The Institute of Safe Medication Practices (ISMP) and the United States Food and Drug
Administration … established error reporting systems allow for the identification of common themes and trends among the … Implementing an error reporting process allows tracking and assessment of error trends that can be
used … An overview of clinical
decision support systems: benefits, risks, and strategies for success.
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - if a wad of packing material was in the vagina, health care providers in this Case relied on perfunctory … Organizational culture should encourage health care providers to communicate and collaborate with each … Applying the knowledge of nursing procedures and psychomotor skills to the techniques of physical assessment … June 18, 2020
Information and power: women of color's experiences interacting with health … care providers in pregnancy and birth.
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - In one study of risk factors for QT prolongation, EHR alerts were shown to increase assessment for QT … only 21% of EHR alerts led to physician action. 9
Systems Change Needed/Quality Improvement Approach …
In response to the Case above, several systems issues can be addressed. … test value is reported to the administration of a repletion dose of potassium. 10 The same systems … A dietary consultation may have also been helpful to provide an assessment of the patient’s nutritional
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psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
August 01, 2010 - of Medicine and Chairman of the Department of Medicine. … Looking at those systems across what we call the customer–supplier relationship between the cath lab … , significant amounts of research, and substantial innovations in both technology and delivery systems … Improving general communication skills between health care providers and consumers is essential in medicine … Healthcare Systems Ergonomics and Patient Safety. London, UK: Taylor & Francis Group; 2005:85.
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psnet.ahrq.gov/periodic-issue/periodic-issue-326
January 07, 2022 - Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage … and adverse events after initial assessment by ambulance clinicians: a cohort analysis. … facing complex healthcare systems into the design of diagnostic safety interventions. … healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers … work product”) developed when a healthcare provider works with a federally listed PSO under the Patient
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - The 2008 Joint Commission Patient Safety Goal 2E requires all health care providers to "implement a standardized … The admitting ICU team evaluated the patient and agreed with the initial assessment (although they were … of clinical inertia (failure of health care providers to initiate or intensify therapy when indicated … Information transfer from prehospital to ED health care providers. … Patient Transport
Intensive Care Units
Emergency Departments
Long-Term Care
Health Care Providers
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - , significant amounts of research, and substantial innovations in both technology and delivery systems … Improving general communication skills between health care providers and consumers is essential in medicine … Healthcare Systems Ergonomics and Patient Safety. London, UK: Taylor & Francis Group; 2005:85. … of Medicine and Chairman of the Department of Medicine. … Looking at those systems across what we call the customer–supplier relationship between the cath lab
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - will always be individual- and systems-level issues that facilitate triggering of the superficial vein … for the sake of another, larger group of clinicians who consume and act upon the terminology (and this … In the case of SFV, the period of change will be marked in years, and the transition may bring about … September 28, 2022
Using the Assessment of Reasoning Tool to facilitate feedback about … Emergency Departments
Health Care Providers
Emergency Medicine
Cardiology
Radiograph Interpretation
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - She logged into the medical record of one of these patients—the wrong one—and saw
a normal CRP value … Ambiguities in the logistics of test result management and
handoffs are areas of vulnerability. … : dissatisfaction with test result management systems in primary care. … SAFER Self-Assessment. Test Results Reporting and Follow-Up. … Improving clinical practice using clinical decision
support systems: a systematic review of trials to
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - As healthcare systems strive to improve outcomes and safety, it is important to focus on the needs of … Prescription Drug Monitoring Programs (PDMPS): What Healthcare Providers Need to Know. https://www.cdc.gov … in healthcare workers during the Covid-19 pandemic: a multinational cross-sectional study. … June 10, 2020
The effectiveness of checklists and error reporting systems in enhancing … Topic
Hospitals
Emergency Departments
Health Care Providers
Anesthesiology
Emergency
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - increasing use of absorbable sutures and the push for healthcare systems to increase value and decrease … of between 13,500 and 86,000 physicians by 2036 and that health systems are responding by expanding … the role of nonphysician health care providers. 30 In addition, in the outpatient setting, medical assistants … Preoperative Patient Assessment and Education Evaluate and if needed treat the patient’s medical comorbidities … Staff Training and Education : Provide ongoing education and training for healthcare providers including
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - Describe the importance of understanding the nature of the acute pain and its relationship to the chronic … of the pain and its relationship to the patient's chronic pain complaint is crucial. … The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. … March 1, 2017
Patient safety, systems design and ergonomics. … Topic
Hospitals
Health Care Providers
Medicine
Opiates/Narcotics
Latent Errors
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - The leadership of organizations—hospitals, health systems, long-term care communities, ambulatory practices … me that healthcare workers should be aware of limitations that families might have based on the situation … Systems and equipment were not in place to handle the situation safely. … Family Presence and Participation During the COVID-19 Pandemic
Most hospitals and health systems responded … A recent Cochrane Systematic review found that power imbalances between healthcare providers and patients
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - vary substantially by the magnitude of the stressor and the extent of underlying cardiac disease, 22 … awareness of CVD as the leading killer of women and better understanding of gender differences in the … record. 33,34 Recent improvements in electronic medical record systems and increasing use of telehealth … Assessment and Treatment of Patients With Type 2 Myocardial Infarction and Acute Nonischemic Myocardial … Topic
Health Professional Students
Residents
Emergency Departments
Health Care Providers
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psnet.ahrq.gov/issue/understanding-and-improving-everyday-work-healthcare
May 13, 2020 - June 21, 0223
- June 21, 2023
Considering human factors and developing systems-thinking … hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. … June 7, 2023
A systems analysis of work-related violence in hospitals: stakeholders, … Consumer Reporting System for Patient Safety Events. … June 14, 2023
Accelerating the Uptake of Safety Initiatives and Guidelines: Role of Implementation
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - understanding of systems thinking and engineering principles—was a marvelous example
of translocational … institutions using a variety of real-world systems. … In health care, the absence of an incentive to focus on
quality and safety, the huge volume of new knowledge … Evidence Report/Technology Assessment No. 43. … Human error and the problem of causality in analysis of accidents.
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - At the time of her
appointment, she described the pain as deep, and 6 out of 10 in severity, concentrated … showed signs of
metastases to the liver and bone, as well as multiple small fractures of the pelvic … Regulatory bodies, health systems, and professional societies have all encouraged
providers to taper … Finally, all healthcare delivery systems should have systems in place to ensure that all patients receive … Although pain management specialists are not available in all health systems and communities, this PCP
-
psnet.ahrq.gov/node/33869/psn-pdf
November 01, 2018 - Pritzker Professor of Medicine, Chief of the Section of Hospital
Medicine, and Director of the Center … For the
better care part of it, we used HCAHPS [Hospital Consumer Assessment of Healthcare Providers … and
Systems] scores to measure patient experience. … We've also been fortunate to
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments … You can lose one of them and take a little while to replace them and not have it be the end of
the world