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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - , treatment, or services. … The implementation of first-fill counseling reinforces understanding of the patient’s treatment plan, … This would have provided an opportunity for the patient to inform the pharmacist of their actual condition … , treatment or services? … An overview of clinical decision support systems: benefits, risks, and strategies for success.
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - hinder achievement of intended clinical outcomes. 1 The intervention was designed to identify potential … Getting Started with This Innovation
Determine the clinical conditions to focus on as part of the … Identify the commonly prescribed medications across the clinical conditions to incorporate into the automated … Develop criteria for identifying patients with a newly prescribed medication associated with one of the clinical … Office
Health Care Providers
Pharmacists
Health Care Executives and Administrators
Side Effects
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - To develop a transition plan of care addressing this broad array of needs, SNF nurses, social workers … and (ii) delineates the domains of a complete transition plan of care, such as medications, advanced … A common barrier to implementing transitional care in SNFs is the scarcity of clinical staff for delivering … for managing activities of daily living or medical care at home. … The case did not include any details of discharge planning or transitional care provided in the SNF.
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psnet.ahrq.gov/issue/workarounds-workplace-second-look
December 08, 2021 - December 8, 2021
Failure to rescue in neonatal care. … Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition … 24, 2020
The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical … peer support program on perceptions of second victim experiences and supportive resources in pediatric clinical … May 20, 2009
Health IT implementation stories: HANDS care plan tool seeks to improve
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - When I give talks I ask two questions, have you or someone you know ever had medical care that you or … I asked him if he had any underlying condition, and he said no. … such as Clostridium difficile colitis.( 2 ) Nevertheless, 71% of patients with acute bronchitis—a condition … The Do No Harm Project, which began at the University of Colorado School of Medicine, collects clinical … Interview
In Conversation With...Amy Helwig about Health Plan
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - four months after starting one of the selected target
medications used to treat four common primary care … hinder achievement of
intended clinical outcomes.1 The intervention was designed to identify potential … The pharmacist followed up with the primary care physician, as needed. … Getting Started with This Innovation
Determine the clinical conditions to focus on as part of the development … Identify the commonly prescribed medications across the clinical conditions to incorporate into the
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - produce a tailored plan of care with each patient. … The nurse creates a plan
that incorporates the interventions and is visible to the care team, patient … in injuries, which can range in severity.12
Unlike other adverse events that require a standardized clinical … various hospital groups, including the Quality and Safety
Committee, nurse managers/directors, and clinical … care plan across the care team, including non-nursing staff
A system for regularly collecting and reporting
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psnet.ahrq.gov/issue/risks-prescribing-cascade
December 16, 2020 - Inappropriate care activities can cascade to significantly impact patient safety. … ": lessons from New York City home-based primary care practices managing COVID-19. … and perceived quality of care. … April 6, 2022
Unite for Safe Care. … View More
See More About The Topic
General Public
Hospitals
Ambulatory Clinic or
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psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - The lack of technology (e.g.,
electronic medical records, clinical decision support systems) to support … physician to engage in effective communication and collaboration related to the patient's assessment
and plan … Collaborate with fellow clinicians to evaluate unusual assessment findings or plans of care. … Clinical practice guidelines for support of the family in the
patient-centered intensive care unit: … care.
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - In this commentary, we
address these issues and provide potential solutions for clinical practice. … prior to the intrahospital transfer, preferably using standardized protocols (e.g., a triage protocol
or … research has focused primarily on nurses and physicians, but failure to speak up is not limited
to clinical … Clinical incidents that may or may not result in patient harm frequently occur during intrahospital … Readers should not interpret any statement in this report as an official position of AHRQ or
of the
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - The second thing is that organizations or health care providers are not organized around teams and do … Every patient is receives care from a lot of people, no matter what condition they come in, and there's … The way health care pays clinical care providers is also a problem. … But in health care a team might have 20 or 30 people, very fluid, and it might be a clerk who has to … During these calls, we helped teams plan their next steps or discuss how to remove obstacles to change
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psnet.ahrq.gov/issue/quality-safety-and-content-telephone-and-face-face-consultations-comparative-study
August 04, 2021 - and less detailed than face-to-face visits for similar clinical problems, increasing the potential for … diagnostic or management errors. … November 12, 2014
Patterns of nurse–physician communication and agreement on the plan … January 19, 2012
Quality of clinical aspects of call handling at Dutch out of hours centres … October 30, 2008
View More
See More About The Topic
Ambulatory Clinic or
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - Over the course of a four-day admission, his condition
moderately improved with bronchodilators, steroids … pharmacy with instructions to
proceed with the medication delivery but did not communicate this change in plan … plan or lack the knowledge or skills to do so.8
Patient empowerment allows patients to assert greater … Hospital Medicine
Department of Internal Medicine
UC Davis Health
Kathie Le, PharmD, BCPS
Senior Clinical … Working Group | Clinical Pharmacy and Pharmacology | JAMA | JAMA Network.
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - , and decision making; and collaboration at all levels of care, not just in direct clinical care. … place for a patient or a resident in long-term care to define their family or care partner, and how … Clinicians were having to treat patients, whether they had COVID or some other serious condition, without … Families can then work collaboratively with nurses to ensure the plan of care is followed. … With the CARE Act, patients are asked to provide a family member or other care partner name for listing
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psnet.ahrq.gov/issue/ask-me-explain-campaign-90-day-intervention-promote-patient-and-family-involvement-care
November 16, 2022 - The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care … Resources From the Same Author(s)
Implementation of the I-PASS handoff program in diverse clinical … to Clinical Deterioration Outside the ICU: 2023. … of parents and health care providers in a tertiary pediatric intensive care unit. … November 23, 2016
Implementation of Condition Help: family teaching and evaluation of
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - With expanded use, there has also been an increase in how telehealth technologies are used in clinical … resulted in emerging concerns regarding patient safety. 3 These concerns are exacerbated by the fact that clinical … When telehealth has been used for on-demand clinical calls using systems and providers that are not a … However, when providers use telehealth to engage with their own patients, patient satisfaction and clinical … telehealth operations to determine clinical circumstances where telehealth has the potential to negatively
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - Diagnostic errors in primary and ambulatory care Diagnostic errors in primary care are common. … delayed diagnoses in the ambulatory care setting ( 2 ), and annually 150,000 or more patients experience … over 2 months with worsening symptoms, yet the diagnostic impression did not change and the management plan … In a controlled study, clinicians were 19% more likely to stick with an initial management plan if confronted … provide guidance about a particular clinical decision at the point of care.
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - looking at diagnostic errors across a disease or clinical condition. … After most studies, current clinical and operational teams are assigned responsibility (or new teams … patients with a certain condition or event. … Electronic clinical surveillance to improve outpatient care: diverse applications within an integrated … or developer of the innovation.
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Diagnostic errors in primary and ambulatory care
Diagnostic errors in primary care are common. … delayed diagnoses in the ambulatory care setting (2), and annually 150,000 or more
patients experience … 2 months with worsening symptoms, yet the
diagnostic impression did not change and the management plan … In a controlled study, clinicians were 19% more likely
to stick with an initial management plan if confronted … provide guidance about a particular clinical decision at the point of care.
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - priority, there is a renewed focus on patient safety
to address systems issues that were brought to light or … With the changes in environment, moral distress, and discomfort with clinical
situations, many clinicians … Safer Together: A National Action Plan to Advance Patient
Safety was released in fall 2020. … The central concept of this plan is total systems safety, that is, applying
principles systematically … a coordinated and comprehensive approach like the recommendations presented in the
National Action Plan