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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015319-sullivan-final-report-2007.pdf
January 01, 2007 - consolidated these domains into four broad categories:
expectations, impact, and fears of e-prescribing, and barriers … Many
of the barriers and challenges identified by other organizations36 currently implementing
commercially … Challenges were thought of as
opportunities for improvement, rather than barriers to adoption. … Overcoming
barriers to adopting and implementing computerized
physician order entry systems in U.S.
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www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/measures-rapid-scan-report.pdf
April 10, 2025 - understand the trajectory of implementation across different organizations
and essential to understand the barriers … What are the barriers or challenges to using implementing or using these measures in
practice? … coordinated use between providers (across team, and between specialties)
If no measures, what are the barriers … How could these barriers be overcome?
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digital.ahrq.gov/sites/default/files/docs/citation/state-regional-demonstration-hit-in-final-report.pdf
July 01, 2015 - The INPC overcame some of the organizational, legal, and technical barriers that have hindered
the development … The INPC overcame some of the organizational, legal, and technical barriers that have hindered the development
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/evidence-map-technical-brief-49-disposition-comments.pdf
September 05, 2024 - in the adequate provision of
HCBS more broadly (e.g., workforce shortages;
language and cultural barriers … Mediators might be seen as
mechanisms of action, such as the facilitators or
barriers shown in this … the extent
of person-centeredness in the described
interventions and the limited information on
barriers … determining the extent of person-
centeredness in the described interventions and
the limited information on barriers
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017190-chueh-final-report-2011.pdf
January 01, 2011 - and marked
shortcomings in the management of such chronic diseases as hypertension and diabetes.5 Barriers … to effective care have been attributed to lack of continuity in care, financial barriers, poor
patient-physician … that ACCORD
had the potential to provide more direct access to the information patients need, reduce barriers … thought that any reduction of the time available for human interaction during office visits would
create barriers
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/prevention-of-human-immunodeficiency-virus-hiv-infection-pre-exposure-prophylaxis
August 22, 2023 - such as Black persons and young persons. 17 , 18
It is important for clinicians to recognize that barriers … These barriers can include structural barriers, such as lack of health insurance, and other factors, … data suggest that PrEP use is lower in transgender women than in men who have sex with men. 21 These barriers
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/6fFns4N2J-t5EGC5BUdRuu
October 23, 2023 - PrEP, such as Black persons and young persons.17,18
It is important for clinicians to recognize that barriers … These barriers can in-
clude structural barriers, such as lack of health insurance, and other
factors … data suggest that PrEP use is lower in transgender
women than in men who have sex with men.21 These barriers
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/chipra-primary-care-physician-reporting.pdf
December 01, 2016 - Interview data suggested that physi-
cians were receptive to quality reporting, but significant barriers … consid-
ered a promising strategy, in this study, state efforts appeared
insufficient to overcome the barriers … on providers’ attitudes toward quality reporting and
improvement, with a focus on facilitators and barriers … Barriers to engaging providers
in quality measurement and
reporting efforts
Resistance to perceived
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/pediatric-ehr_disposition-comments.pdf
May 01, 2015 - will also identify evidence on levels of use, and
usability of HIE, as well as facilitators of and barriers … Regarding the cost of licensed content, we have added a
comment as such into the barriers to implementation … For GQ2 – were the key
informants asked about the potential opportunities or
just barriers? GQ3. … will also
identify evidence on levels of use, and usability of HIE, as
well as facilitators of and barriers … Peer Reviewer
#7
Next Steps This seems awfully short based on all the ideas and
barriers and needs
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www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf
July 01, 2004 - Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency
105
Fundamentals of Medicare Patient
Safety Surveillance: Intent, Relevance,
and Transparency
David R. Hunt, Nancy Verzier, Susan L. Abend, Courtney Lyder,
Lisa J. Jaser, Nancy Safer, Paul Davern
Abstract
The Medicar…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
July 01, 2004 - Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency
105
Fundamentals of Medicare Patient
Safety Surveillance: Intent, Relevance,
and Transparency
David R. Hunt, Nancy Verzier, Susan L. Abend, Courtney Lyder,
Lisa J. Jaser, Nancy Safer, Paul Davern
Abstract
The Medicar…
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effectivehealthcare.ahrq.gov/sites/default/files/01_arthritis_potential_high_impact_2012-12-10.pdf
January 01, 2012 - out-of-pocket cost of the procedure, availability of the procedure, and the
use of stem cells may serve as barriers … These safety concerns could present significant barriers to diffusion. … increases in cholesterol levels, and liver damage in some patients, were also cited as potential
barriers
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www.ahrq.gov/ncepcr/reports/primary-care-research/results.html
January 01, 2024 - Barriers to care coordination include: fragmentation of clinical information technology (i.e., lack of … faced by providers, practices, and health systems in providing coordinated care; and patient-specific barriers … For example, EvidenceNOW projects have both elucidated the barriers to obtaining consistent and reliable … Bates) identified EHR use and barriers to adoption among Massachusetts primary care practices. 156 … Building on an AHRQ-supported project to identify challenges and barriers to CDS design and implementation
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effectivehealthcare.ahrq.gov/sites/default/files/obesity-horizon-scan-high-impact-1312.pdf
December 01, 2013 - Pricing,
reimbursement, and prescribing barriers have been the priority for the manufacturers of lorcaserin … However,
costs and lack of insurance coverage could be barriers to adoption by some patients and could … pharmacotherapies and many third-party payers’ unwillingness to cover these drugs might serve as
barriers … Most experts agreed that other notable barriers to wide
15
acceptance of liraglutide might be … prescribe the drug electronically through local
pharmacies for a 3-month supply at a time, so logistical barriers
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/2021-uspstf-annual-report-to-congress.pdf
January 01, 2021 - Institute calls for the medical and research communities to break through
assumptions about perceived barriers … communities NHMA members serve, increase cultural competency, and decrease
language and health literacy barriers … disparities in use
and in patient acceptance of clinical preventive services for these diseases, and how barriers
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/personcentered/qdr2015-chartbook-personcenteredcare.pptx
September 01, 2016 - Communication
Optimal health care requires good communication between patients and providers, yet barriers
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www.ahrq.gov/patient-safety/reports/liability/baker.html
August 01, 2017 - Improvement Tracking in Primary Care Practices: Lessons Learned
Implementing Shared Decision-Making: Barriers
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mrsa-screening-2010_executive.pdf
January 01, 2010 - However, cluster
RCTs may also face barriers to feasibility due to the
large number of institutions