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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - The 2008 Joint Commission Patient
Safety Goal 2E requires all health care providers to "implement a … Many health care systems require EMS providers to radio the receiving ED prior
to arrival. … 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.
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - painful areas, and thorough neurologic assessment including reflexes, grading of muscle activity, sensory … assessment, and gait. … In patients with severe symptoms or risk factors, a post-void residual bladder volume and assessment … The goals of surgical management are to preserve neurologic function and to control the source of the … communicate a history, or a patient unwilling to undergo testing or evaluation necessary for diagnosis. 34 Systems
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - We have relatively superficial understandings of the causes of even
common errors and adverse events … For instance, computerized order entry systems and greater participation of pharmacists in
https://psnet.ahrq.gov … , the frequent use of before-after designs, and the subjective nature of many important
outcomes create … Safety culture assessment: a tool for improving patient safety in healthcare
organizations. … Role of computerized physician order entry systems in facilitating
medication errors.
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - Determine systems approaches that facilitate advance care planning between the healthcare team,
patient … It is important for health care providers and the lay public alike to understand that DN(A)R increasingly … Health care providers may sometimes erroneously interpret
DN(A)R status to mean that a patient wants … medical school and postgraduate training along with systems-level designs would help “close the loop … and
other EHR systems to make code status a prominent and easily-seen entry near or at the top of the
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - Use of TEE allows direct visualization of cardiac filling and contractility, as well as assessment of … Research has shown that such systems improve response time and overall patient outcomes. 21
The … , both in identification and communication of the risk and in the use of appropriate mitigating strategies … Comparison of Early Warning Scoring Systems for Hospitalized Patients With and Without Infection at Risk … Topic
Operating Room
Health Care Providers
Surgery
Orthopedic Surgery
Surgical Complications
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
March 29, 2023 - of the procedure and ultimately to an unsatisfactory conclusion with discharge of the patient against … This risk-benefit assessment needs to be performed individually based on the specific clinical situation … A detailed history of the timing of the ingestion and the nature of the foreign body is important, as … assessment. 30 Conclusion This patient probably did not suffer any harm as a result of this communication … Departments
Operating Room
Health Care Providers
Nurses
Emergency Medicine
View
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - Risk mitigation measures, such as urine toxicology screening, patient contracts, and risk assessment … prescriber PDMP use and providing integrated query systems that minimize provider burden will help to … While there are no perfect risk assessment instruments, universal screening and triaging of chronic opioid … that people need more and more of the drug to achieve the same effect. … May 8, 2017
Assessment of the FDA Risk Evaluation and Mitigation Strategy for transmucosal
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - Describe the importance of understanding the nature of the acute pain and its relationship to the
chronic … The oral route of administration is preferred when possible to maximize
duration of action and reduce … Morphine and hydromorphone should be dose reduced in the
setting of renal failure, and benzodiazepines … Take-Home Points
Taking a thorough history regarding the nature of the pain, and differentiating acute … The opioid abuse and misuse epidemic: implications for
pharmacists in hospitals and health systems.
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - That afternoon, the intern checked the results and noted the first line of the final result stated "Positive … They were reviewing the plan of care and discussed the reason for the IVC filter (an unusual intervention … The senior resident reviewed all of the radiology records and read the original ultrasound report, which … widely used in the treatment and prevention of VTE. … Topic
Intensive Care Units
Health Care Providers
Critical Care
Diagnostic Test Interpretation
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - media, even the best systems may not protect them. … So I think it's a combination of both people and systems. … between the role that systems play in problems and the role that people play in problems, and the interplay … importance of searching for systems factors, without immediately zeroing in on more dramatic and obvious … Topic
Hospitals
Health Care Providers
Health Care Executives and Administrators
Active
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - he is also director of the Division of Clinical Pharmacology and Toxicology. … that people need more and more of the drug to achieve the same effect. … Risk mitigation measures, such as urine toxicology screening, patient contracts, and risk assessment … prescriber PDMP use and providing integrated query systems that minimize provider burden will help to … While there are no perfect risk assessment instruments, universal screening and triaging of chronic opioid
-
psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - systems conducted their own internal efforts, and all 220 California hospitals were
exposed to state-wide … and approaches of the initiative. … Safety assessment of a large-scale
improvement collaborative to reduce nulliparous cesarean delivery … Safety Assessment of a Large-Scale
Improvement Collaborative to Reduce Nulliparous Cesarean Delivery … Safety Assessment of a Large-Scale
Improvement Collaborative to Reduce Nulliparous Cesarean Delivery
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - The patient had a normal radiograph of her left foot and ankle. … name, there will always be individual- and systems-level issues that
facilitate triggering of the superficial … 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 … although "adenoma" usually connotes benignity
Preoperative
clearance
• "clearance" implies certainty in assessment
-
psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - vary substantially by the magnitude of the stressor and
the extent of underlying cardiac disease,22 … as the leading killer of women and better understanding of gender
differences in the presentation and … record.33,34 Recent
improvements in electronic medical record systems and increasing use of telehealth … Pharmacotherapy Self-Assessment Program, seventh
edition (PSAP-VII) Cardiology.2020:179-99.
13. … Assessment
and Treatment of Patients With Type 2 Myocardial Infarction and Acute Nonischemic Myocardial
-
psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - of staff time per transfer, and 11.3 full-
time equivalents in nursing time over the course of a year … , during transfer, and
posttransfer.(4)
Pretransfer preparation should include an assessment of the … Pretransfer activities should also include both the transfer
coordination and the testing and use of … in the assembly of needed equipment and medications. … Guidelines for the inter- and intrahospital transport of critically ill patients.
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - In 2010, the Association for the Advancement of Medical
Instrumentation and the U.S. … light-linking systems.17 While
additional research will be required to determine which of these solutions … 2) placement of labels in two standard locations,
below the smart pump and near the distal end of the … Ontario health technology assessment
series. 2014;14(5):1.
18. … Ontario health technology
assessment series. 2012;12(16):1.
43. Furniss D, Back J, Blandford A.
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - patient population with massive or
submassive PE, streamline patient assessment, and facilitate and … latent systems issues. … , and systems
modifications. … Healthcare systems should continually evaluate for and address communication barriers that lead to these … Multimodality Assessment of Right Ventricular Strain in
Patients With Acute Pulmonary Embolism.
-
psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - These best practices include, but are not limited to, comprehensive identification and assessment of … Identification and Assessment of High-Risk Patients
Risk factors for opioid-induced respiratory depression … , assessment and documentation of patient responses to opioid administration. 30 In postoperative patients … database, the interval between the last nursing assessment and detection of respiratory depression was … Safety assessment of postoperative pain management by an acute pain service.
-
psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - EC : Very interesting work has come out of the design of computer systems and human–computer interaction … EC : I don't believe that the design of modern health IT systems actually reflects this literature and … Most modern e-health systems presume that the user is not doing anything else and that the screen has … It's very important to recognize that these devices are built for the consumer world; while they're very … Topic
Hospitals
Health Care Providers
Quality and Safety Professionals
Information Professionals
-
psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - EC : Very interesting work has come out of the design of computer systems and human–computer interaction … They teach us a lot about the sorts of systems we can eventually put in place to minimize distraction … EC : I don't believe that the design of modern health IT systems actually reflects this literature and … Most modern e-health systems presume that the user is not doing anything else and that the screen has … It's very important to recognize that these devices are built for the consumer world; while they're very