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Oral medications inadvertently given via the intravenous route. | PSNet

psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route

October 05, 2016 - June 18, 2014 Managing patient access and flow in the emergency department to improve … services. … Employee safety climate and patient safety culture in health care. … A systematic review at the Department of Veterans Affairs. … February 22, 2024 National and State Healthcare-Associated Infections Progress Report

Can teamwork promote safety in organizations? | PSNet

psnet.ahrq.gov/issue/can-teamwork-promote-safety-organizations

April 24, 2019 - January 23, 2019 The anatomy of health care team training and the state of practice: … February 25, 2009 Improving health care quality and patient safety through peer-to-peer … May 5, 2021 Variability in collection and use of race/ethnicity and language data in … November 8, 2017 Breast cancer treatment delays by socioeconomic and health care access … August 24, 2022 A state-of-the-art review of speaking up in healthcare.

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system. | PSNet

psnet.ahrq.gov/issue/association-acute-covid-19-infection-patient-safety-indicator-12-events-multisite-healthcare

January 18, 2023 - 2020: a summary of data reported to the National Healthcare Safety Network. … with language proficiency in the US. … of incidents reported to the National Reporting and Learning System. … September 2, 2020 Breast cancer treatment delays by socioeconomic and health care access … efforts.

Discharge missteps can send seniors back to hospital. | PSNet

psnet.ahrq.gov/issue/discharge-missteps-can-send-seniors-back-hospital

December 05, 2007 - March 8, 2023 Health Care Simulation to Advance Safety: Responding to Ebola and Other … Safety Risks and Harms in Ambulatory Health Care Settings. … A COVID-19 Resource for Hospital and Health System Leaders. … January 17, 2024 New Covid boosters look a lot like the old ones. … Examining the frequency, types and senders of pages in academic medical services.

The Unfinished Patient Safety Agenda | PSNet

psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda

August 01, 2005 - Efforts to transform care at the bedside, including improved nurse staffing and working conditions, must … The tighter the system is, and the more we all look at it from an interdisciplinary perspective, the … Department of Health and Human Services. … Department of Health and Human Services. … May 13, 2015 Developing a common language for evaluation questions in quality and safety

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes. | PSNet

psnet.ahrq.gov/issue/bridging-feedback-gap-sociotechnical-approach-informing-clinicians-patients-subsequent

October 17, 2018 - care team, and in a structured format to ensure relevance and usefulness. … in a learning health system. … to 20 hospitals in England during implementation of the 7-day services national health policy. … November 25, 2020 Impact of providing patients access to electronic health records on … December 7, 2022 Unintended consequences of patient online access to health records:

HospitalInspections.org | PSNet

psnet.ahrq.gov/issue/hospitalinspectionsorg

March 25, 2024 - complaint inspections at acute care and critical access hospitals. … October 30, 2013 A Crisis in Health Care: A Call to Action on Physician Burnout. … April 7, 2021 Communication in health care: impact of language and accent on health care … April 5, 2023 A systematic review of the effect of telepharmacy services in the community … to ensure safe care at the direct care level.

Bullying of junior doctors prevails in Irish health system: a bitter reality. | PSNet

psnet.ahrq.gov/issue/bullying-junior-doctors-prevails-irish-health-system-bitter-reality

July 15, 2020 - patient safety efforts in infection prevention: a multi-center qualitative study. … services: a qualitative study. … on safety issues in UK mental health services. … services in healthcare settings: a study of health information exchange. … July 15, 2020 Clinical reasoning education at US medical schools: results from a national

Diagnostic Delay in the Emergency Department | PSNet

psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department

January 01, 2016 - visits to the ED that led to a hospitalization could be a useful way to look for these missed opportunities … [Available at] 7. Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care. … Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine … Department of Health and Human Services. … Department of Health and Human Services.

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre. | PSNet

psnet.ahrq.gov/issue/impact-structured-interdisciplinary-bedside-rounding-patient-outcomes-large-academic-health

December 09, 2020 - Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health … February 5, 2020 Impact of providing patients access to electronic health records on … to 20 hospitals in England during implementation of the 7-day services national health policy. … threats: a national survey of interns and residents. … Examining the frequency, types and senders of pages in academic medical services.

Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy. | PSNet

psnet.ahrq.gov/issue/speaking-factors-and-issues-nurses-advocating-patients-when-patients-are-jeopardy

March 29, 2023 - July 22, 2020 Latent safety threats and countermeasures in the operating theater: a national … to prioritize efforts to improve cancer care delivery. … in health care: a battle to be heard, believed, and protected. … March 17, 2021 The I-READI quality and safety framework: a health system’s response to … standards accelerated integration and expansion of tools and services in the Veterans Health Administration

Ensuring primary care diagnostic quality in the era of telemedicine. | PSNet

psnet.ahrq.gov/issue/ensuring-primary-care-diagnostic-quality-era-telemedicine

May 25, 2022 - the National Academies' report Improving Diagnosis in Health Care. … to 20 hospitals in England during implementation of the 7-day services national health policy. … language proficiency in the US. … Telemental Health Care at VA Clinic Locations Prior to the Pandemic. … May 5, 2021 Improving Telediagnosis: A Call to Action.

Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet

psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again

November 01, 2006 - of Michigan Health System *Acknowledgement: Lisa Lau, a human factors engineer at VA National Center … So that you can look at it and you can see roughly where you are within the important parameters and … Today it's quite common for physicians to turn to a book or a computer and look something up and come … Department of Health and Human Services. … Department of Health and Human Services.

How communication "failed" or "saved the day": counterfactual accounts of medical errors. | PSNet

psnet.ahrq.gov/issue/how-communication-failed-or-saved-day-counterfactual-accounts-medical-errors

March 14, 2022 - to 20 hospitals in England during implementation of the 7-day services national health policy. … October 13, 2021 Clinical reasoning education at US medical schools: results from a national … April 12, 2023 Quality and safety in hospital pediatrics during COVID-19: a national … June 22, 2022 Delayed access to care and late presentations in children during the COVID … October 7, 2020 Variability in collection and use of race/ethnicity and language data

Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. | PSNet

psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and

December 16, 2020 - language proficiency in the US. … A national prospective cohort study. … March 6, 2005 Improving medication reconciliation with comprehensive evaluation at a … September 30, 2023 Feds move to rein in prior authorization, a system that harms and … February 15, 2023 New Covid boosters look a lot like the old ones.

In Conversation with…Thomas J. Nasca, MD | PSNet

psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md

February 01, 2010 - go through to begin to look at that. … And we also must look at level of training in crafting duty hours. … boards that we will have the ability to look at performance predictors in residency and link that to … Department of Health and Human Services. … Department of Health and Human Services.

Nurses as a source of system-level resilience: Secondary analysis of qualitative data from a study of intravenous infusion safety in English hospitals. | PSNet

psnet.ahrq.gov/issue/nurses-source-system-level-resilience-secondary-analysis-qualitative-data-study-intravenous

July 22, 2020 - August 4, 2021 Health professionals' perspectives of safety issues in mental health services … June 29, 2022 Variability in collection and use of race/ethnicity and language data in … January 27, 2021 Impact of providing patients access to electronic health records on … UK national health service. … EHR medication reconciliation at a health system.

Vulnerability of the medical product supply chain: the wake-up call of COVID-19. | PSNet

psnet.ahrq.gov/issue/vulnerability-medical-product-supply-chain-wake-call-covid-19

June 22, 2022 - to 20 hospitals in England during implementation of the 7-day services national health policy. … threats: a national survey of interns and residents. … English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based … November 11, 2020 Impact of providing patients access to electronic health records on … services in healthcare settings: a study of health information exchange.

Caution, Interrupted | PSNet

psnet.ahrq.gov/web-mm/caution-interrupted

October 01, 2016 - have "look-alike" brand names; (iv) A pharmacy technician trainee was working in IV medication preparation … Similar efforts have begun in some areas of health care ( 14 ), but have yet to be implemented in a comprehensive … Department of Health and Human Services. … Department of Health and Human Services. … investigation at a VA hospital in West Virginia.

In Conversation With… David Blumenthal, MD, MPP | PSNet

psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp

July 01, 2012 - is look at the net benefit. … look at their patients. … For all I know, we will have such capable natural language processing that people will never look at … Department of Health and Human Services. … Department of Health and Human Services.

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