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psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
March 27, 2024 - for, respond to, and recover from cyberattacks much more quickly and effectively in the future and, ultimately … Ultimately, you have an attack, and suddenly incident command is triggered. … Mostly your building systems may be on, but ultimately, all the technology that you normally relied on … And ultimately, when hospitals are attacked with ransomware, lives are threatened, and we need to plan
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psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - While surviving the emergent
resuscitation, the patient ultimately suffered additional complications … Unfortunately, his effusion progressed to cause
hemodynamic compromise from which he ultimately succumbed
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - The patient developed acute kidney injury, which
subsequently subsided, and she ultimately was discharged … Ultimately, this is an unfortunate case of toxicity that could probably have been prevented by a systematic
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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - Her blood cultures ultimately grew Escherichia coli, which may have
spread from her bowel to her bloodstream … Ultimately, she
recovered and was discharged home a week later.
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psnet.ahrq.gov/web-mm/communication-consultants
October 01, 2018 - She became progressively tachypneic with an increasing oxygen requirement, ultimately requiring intubation … multiple communication failures, necessary care was delayed, and the patient rapidly deteriorated and ultimately
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psnet.ahrq.gov/node/34871/psn-pdf
February 09, 2011 - Educational levels of hospital nurses and surgical patient
mortality.
February 9, 2011
Aiken LH, Clarke S, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality.
JAMA. 2003;290(12):1617-1623.
https://psnet.ahrq.gov/issue/educational-levels-hospital-nurses-and-surgical-patient-morta…
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - community, and really across the continuum of care, is to increase medication optimization and safety,
and ultimately … Ultimately, we talked about
community pharmacies being the final safety net for that patient before … Engaging patients in their own care is really important because ultimately, the patient can give you
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - The Joint Commission requires annual drills to identify areas of improvement and success,
ultimately … Regular obstetric simulations can improve team communication, processes and collaboration,
ultimately
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - inadequate response manifested by failure to perform appropriate testing and
delayed treatment for an ultimately … "failure-to-rescue—nursing," was shown to be associated with nurse staffing and skill mix, and was
ultimately
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psnet.ahrq.gov/node/861764/psn-pdf
January 31, 2024 - Low rate of completion of recommended tests and
referrals in an academic primary care practice with
resident trainees.
January 31, 2024
Amat MJ, Anderson TS, Shafiq U, et al. Low rate of completion of recommended tests and referrals in an
academic primary care practice with resident trainees. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/40321/psn-pdf
March 30, 2011 - Inaccuracies in assignment of clinical stage for localized
prostate cancer.
March 30, 2011
Reese AC, Sadetsky N, Carroll PR, et al. Inaccuracies in assignment of clinical stage for localized prostate
cancer. Cancer. 2011;117(2):283-9. doi:10.1002/cncr.25596.
https://psnet.ahrq.gov/issue/inaccuracies-assignment-cli…
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psnet.ahrq.gov/node/866584/psn-pdf
August 28, 2024 - Raising the barcode: improving medication safety
behaviours through a behavioural science-informed
feedback intervention. A quality improvement project and
difference-in-difference analysis.
August 28, 2024
Grailey K, Brazier A, Franklin BD, et al. Raising the barcode: improving medication safety behaviours
throu…
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - primary care physicians, with 83.1 million visits occurring in 2002 (1) , of which 3.1 million were ultimately … Despite aggressive antifungal therapy, the patient ultimately succumbed to
overwhelming infection and
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - Ultimately, the primary care provider called the insurance company directly and was informed that if … Ultimately, we need to better understand why our health care system has evolved to be so complex that
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - The patient had a prolonged postoperative course with intra-abdominal infection before ultimately dying … Ultimately, if the process goes uninterrupted, death may result, from either septic or hypovolemic shock
-
psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - Frailty is ultimately
associated with increased mortality. … allowing our
patients to get deconditioned while we’re presumably healing them is also not acceptable and ultimately
-
psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - Ultimately, he required placement
of bilateral pleural catheters to manage reaccumulation of the pleural … , reduced night staffing, poorly calibrated trainee autonomy, and cultural hierarchy
barriers that ultimately
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psnet.ahrq.gov/node/49753/psn-pdf
February 01, 2016 - The urologist persisted in using the robotic technology and ultimately was able to complete the
procedure … The patient ultimately required several additional
surgeries and a prolonged hospital stay. … In general, surgical outcomes are ultimately a direct manifestation of the skill and experience of the
-
psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - between the operating room nursing staff and the emergency department, the blood bank, the surgeons and, ultimately … In this scenario, the blood banking and transfusion checks ultimately shed light on the identification
-
psnet.ahrq.gov/node/49424/psn-pdf
November 01, 2003 - After
significant delay, the patient was ultimately anesthetized and underwent C-section. … crisis, but can give providers a set of tools to make their responses
more rational, productive, and ultimately