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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - Research published in 2023 identified and built on the following established communication strategies … The 2023 literature published on PSNet emphasized communication and teamwork training as a strategy to … The growing role of technology in healthcare presents a need for further research into the role of technology … Although the importance of patient engagement is clear, further research is needed on how to better engage … The Joint Commission. Sentinel Event Data 2022 Annual Review . The Joint Commission; 2023.
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Again, this is a bit of a data-free zone, and I believe that local culture will determine the "goodness … The IHI has a considerable amount of additional information on RRTs on its Web site and is holding … doctor part of the time and a policy person on the side? … , through the use of run charts and time series statistics, profound changes. … DB: We have a set of values that we try to use here that guide the operational culture of the organization
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psnet.ahrq.gov/node/45564/psn-pdf
October 03, 2017 - https://psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-and-costs
The lack of effective … This commentary recommends ways to enhance the use of quality and safety measures, including
establishing … an entity responsible for setting health data standards, developing a robust scientific approach
to … performance measurement, and improving how this data is communicated to patients. … fostering-transparency-outcomes-quality-safety-and-costs
https://psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - For the hospitalist, lack of access to outpatient clinic notes, labs, and other significant data impedes … the hospitalist about the pending admission, (iv) the PCP then calls a report to the hospitalist on … on the floor. … The effect of hospital occupancy on emergency department length of stay and patient disposition. … communication and agreement on the plan of care.
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - ) psychiatrist, a resident in the final year of training and due to
graduate at the end of June. … Unfortunately, in the world of modern health care, scheduling usually happens on a trial and error basis … It is also satisfactory to the physicians as
they can anticipate their workload on a given day. … are sufficient (these resources can be estimated using the core component of operations research, queuing … Given the unknown number of unscheduled patients coming to the office on a particular
day, the schedule
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - He suggested that we could use the critical incident technique to actually study the kinds of errors … tell, that was the first use of the term "patient safety." … Despite Jeep's leadership, the publication of data pointing to major problems in anesthesia safety and … to many factors: the availability of data (both qualitative and quantitative) that identified many of … The owners lived on the grounds of the first factory.
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - He suggested that we could use the critical incident technique to actually study the kinds of errors … tell, that was the first use of the term "patient safety." … Despite Jeep's leadership, the publication of data pointing to major problems in anesthesia safety and … to many factors: the availability of data (both qualitative and quantitative) that identified many of … The owners lived on the grounds of the first factory.
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psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - The sharp and larger
diameter–tipped cannulae have, for the most part, faded out of use primarily because … The period for evaluation prior to discharge on any patient should be based on a
validated scoring system … One must be careful not to use any of the above as an indictment of office surgery procedures, since … In view of this, the ASPS convened a task force on patient safety in office-based facilities. … bearing on the frequency of
safe outcomes.
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - When they really dug into the data, they found that of about 1750
patients seen in 2003, about 40 patients … ,
and then put it to good use. … But of course to deliver on the value of all those discoveries, the pieces have to come
back together … Academic medical centers and major teaching hospitals are
organized around the teaching and research … That comes back to the basic premise of the
research I've been doing over many years, which is that
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Although
articles highlighted several types of care transitions, much of the research focused specifically … Research published in 2023 identified and built on the
following established communication strategies … The 2023 literature published on PSNet emphasized communication and teamwork training as a strategy to … The growing role of
technology in healthcare presents a need for further research into the role of technology … The Joint Commission. Sentinel Event Data 2022 Annual Review. The Joint Commission; 2023.
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psnet.ahrq.gov/node/49729/psn-pdf
April 01, 2015 - The evidence supporting the use of D-dimer has been mixed.(10) A meta-
analysis involving seven studies … should not
exclude the possibility of AAD based solely on the absence of tearing chest pain, pulse … Since the patient did not have a known history of TIA nor was she on aspirin to account
for her GI bleeding … Aortic dissections: "tearing" apart the data. CMPA Bulletin, R10812E; June 2008.
16. Lo BM. … This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare
Research
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - First, the increasing use is related to the
availability of these devices, and the increasing availability … Together, these data support the hypothesis that catheter fatigue and stress play a role in breakage. … Another factor was
the use of a small syringe for flushing. … Some investigators have called
for the development of a new material or surface coating on the PICC … This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare
Research
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - data in a succinct written format (whether paper or electronic). … pertinent data contained on their
runsheets.(8) Some systems require the ED nurse or physician to sign … Based on the minimal information at hand (the
history of shortness of breath, the low oxygen levels, … Based on this
vital piece of information, the team became concerned that a pulmonary embolism (blood … This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare
Research
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - In the space of only a few years, we have pivoted smartly on this issue and, in part through your research … , and a smattering of tricyclics and so on. … But my point is that what the patients on a nonsteroidal don't have is a drug or class of drugs that … There is a role for the use of opioids in the treatment of chronic pain. … data: a systematic review.
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - in data collection methodologies and practices across hospitals. … Emergency Care Research Institute (ECRI) rated infusion mix-ups as one of the top 10 health
technology … , additional research is necessary to identify and examine the
effects of risk reduction strategies … Utilization of Smart Pumps
The use of smart pumps with ‘dose error reduction software’ is becoming more … For example, ISMP supports 1) use of black and
white medication labels (with the exception of the emergency
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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - Data increasingly support taking a systems perspective; for example, a recent meta-analysis concluded … Others have focused on the importance of changing the health care culture with respect to well-
being … Current Context
The Agency for Healthcare Research and Quality has been funding research on physician … as a consequence of the COVID-19 pandemic. … research and education related to
clinician wellbeing.13 In early work on burnout, the focus was on
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Like the fall prevention plan, the
patient safety plan should be based on a thorough assessment of patient … The effectiveness
of a tailored fall prevention plan relies on an accurate risk assessment, so a mandatory … Use of a validated fall risk screening tool can help identify risks and guide development of an
individualized … Use of bedside tools to communicate the tailored fall prevention plan to all team members, including … Data & Statistics (WISQARS): Cost of Injury Reports.
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - based on recent
patterns of use. … There are persuasive
considerations to support the use of either strategy; however, the benefits of … The use of weight-based dosing may be an advantage in patient populations where physiologic doses of … Active surveillance of medication pump entry data and guardrail overrides can assist in identifying … Evaluating the impact of obesity on safety and efficacy of
weight-based norepinephrine dosing in septic
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - When they really dug into the data, they found that of about 1750 patients seen in 2003, about 40 patients … , and then put it to good use. … But of course to deliver on the value of all those discoveries, the pieces have to come back together … That comes back to the basic premise of the research I've been doing over many years, which is that some … More research is needed to understand which types of problems are best resolved at the individual, unit
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Two health care providers noted her tanned skin and inquired about use of tanning salons. … Primary AI is rare – affecting on the order of 1 in 10,000 individuals 2-4 – and can be related to autoimmune … Although this commentary’s primary focus is on AI as a cause of fatigue and weight loss, the differential … Primary adrenal insufficiency in childhood: data from a large nationwide cohort. … January 18, 2023
Impact of the Agency for Healthcare Research and Quality's Safety Program