-
psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - The patient's nurse noticed that there were no orders for venous
thromboembolism (VTE) prophylaxis, … despite the patient being at high risk for VTE. … The intern assumed that VTE prophylaxis was contraindicated, since the fellow had not
ordered VTE prophylaxis … recalled an incident during medical school where a surgery intern had
been chastised for starting VTE … Therefore, the patient
was not prescribed VTE prophylaxis.
-
psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - on other aspects of safety besides correct
diagnosis (e.g., sepsis bundles, or prophylaxis against venous … thromboembolism), shift-based care, a de-
emphasis on gathering information directly from the patient
-
psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - checklist is completed or the proportion of patients in a hospital receiving appropriate prophylaxis for venous … thromboembolism.
-
psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - advanced indicators” of patient safety outcomes such as avoidable deaths due to health care-associated venous … thromboembolism, sepsis, or patient falls; in-hospital pressure ulcers; and ventilator-associated pneumonia
-
psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - advanced
indicators” of patient safety outcomes such as avoidable deaths due to health care-associated venous … thromboembolism, sepsis, or patient falls; in-hospital pressure ulcers; and ventilator-associated pneumonia
-
psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - 2022
Patient Safety Innovations
The Johns Hopkins Venous … Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital … Associated VTE
April 7, 2022
View More
See More About The Topic
-
psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - the patient with full-dose anticoagulation (rather than lower dose
anticoagulation, appropriate for venous … thromboembolism prophylaxis).
-
psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - vascular catheter management, elevation of head of bed in mechanically ventilated patients,
prevention of venous … thromboembolism).
-
psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - vascular catheter management, elevation of head of bed in mechanically ventilated patients, prevention of venous … thromboembolism).
-
psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - November 15, 2023
Just what the doctor ordered: missed ordering of venous thromboembolism … chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients.
-
psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - case review committee discovered the patient had been given low-molecular-weight heparin (LMWH) for
venous … thromboembolism (VTE) prophylaxis during the first admission. … record (EHR), and that she was used to ordering it as
nearly all patients she admitted met criteria for VTE … this case, the
admitting provider stated that nearly all patients she admitted met the criteria for VTE … combination
of large volumes of information, inappropriate application of her usual practice (giving VTE
-
psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous … thromboembolism?
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - influenza vaccinations to a patient during a single hospitalization
Development of bleeding from venous … thromboembolism prophylaxis that did not adequately outline contraindications to the use of heparins
-
psnet.ahrq.gov/node/33847/psn-pdf
August 01, 2017 - You could do a technically beautiful operation, but if you did not give them
optimal VTE [venous thromboembolism
-
psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - the patient with full-dose anticoagulation (rather than lower dose anticoagulation, appropriate for venous … thromboembolism prophylaxis).
-
psnet.ahrq.gov/node/33751/psn-pdf
January 01, 2014 - program, including process measures focused on the
prevention of surgical infection, postoperative venous … thromboembolism, and postoperative cardiovascular
complications.
-
psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Prolonged hospital bedrest leads to loss of muscle and bone
mass and increases risk of pressure ulcers, venous … thromboembolism and hospital acquired-infection
-
psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - August 1, 2012
National Partnership for Maternal Safety: Consensus Bundle on Venous … Thromboembolism.
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
-
psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…