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psnet.ahrq.gov/issue/annual-speak-data-reports
September 14, 2022 - April 18, 2018
Digital Clinical Safety Strategy
October 20, 2021 … July 26, 2023
Safer Together: A National Action Plan to Advance Patient Safety. … September 16, 2020
Care Compare. … July 1, 2020
Medicine Safety: Take Care. … Ambulatory Clinic or Office
Outpatient Pharmacy
Medicine
View More
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - He was treated with antibiotics and bowel rest and discharged three days later with a plan to follow … of sepsis or worsening clinical symptoms. … Errors in Clinical Judgement
Clinical decision making is a complex process which depends on the ability … While the patient’s clinical evaluation did not necessitate admission or emergency surgery at this point … and clinical outcomes: a systematic review and meta-analysis.
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - She was eventually successfully extubated and discharged home in good condition. … Recent European/American clinical practice guidelines have suggested that noninvasive ventilation be … Protocol directed weaning from mechanical ventilation: clinical outcome in patients randomized for a … Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. … Units
Health Care Providers
Critical Care
Pulmonology
Nonsurgical Procedural Complications
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - The virtual hospitalists were able to address patient and family communication, write clinical notes, … This group of workers required rapid onboarding to start their new clinical roles. 1
Description of … They also assisted with planning and executing clinical care and focused on communication with patients … or developer of the innovation. … Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - Devices in this class submit non-clinical, and
sometimes clinical, evidence to demonstrate equivalence … Class III: Devices that “sustain or support life, are implanted, or present potential high risk of illness … or injury.” … , reduce errors and adverse events, and
support innovation care practices. … The Action Plan highlights the enhancements the FDA has made- or is making- to their
oversight of device
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psnet.ahrq.gov/issue/effectiveness-and-cost-transitional-care-program-heart-failure-prospective-study-concurrent
April 24, 2019 - Study
Effectiveness and cost of a transitional care program for heart failure: a … April 24, 2019
Association of clinical specialty with symptoms of burnout and career … September 26, 2018
Association of opioid-related adverse drug events with clinical and … January 12, 2022
Clinical reasoning assessment methods: a scoping review and practical … June 26, 2019
Drawing boundaries: the difficulty in defining clinical reasoning.
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - Events (CTCAE) in cancer therapy from the National Cancer Institute (i.e., painful erythema, edema, or … ulcers but eating or swallowing possible). … The ultimate clinical outcome was
unchanged, possibly reinforcing the provider’s clinical reasoning … diagnosis
of oral mucositis will lead to appropriate therapy and improvement of the patient’s overall condition … Cross-cover care is a core activity for all inpatient providers and there are clinical competencies that
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - was subtherapeutic on her anticoagulation with warfarin, and a heparin drip was initiated with the plan … or patient outcomes. … First, patients may have important health care matters neglected when physicians or nurses shift their … Interview
In Conversation With...Amy Helwig about Health Plan … July 10, 2024
Perspectives on Safety
Health Plan
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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - She was then transferred to the
intensive care unit (ICU). … She was eventually successfully extubated and discharged home in good condition. … Recent
European/American clinical practice guidelines have suggested that noninvasive ventilation be … Am J Respir Crit Care Med. 1998;158:489-493. … Am J Respir Crit Care Med. 2017;195:120-133. [go to
PubMed]
7.
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psnet.ahrq.gov/issue/disclosure-medical-errors-what-factors-influence-how-patients-respond
December 23, 2008 - This study concluded that full disclosure either has a positive effect or no effect on the way patients … than 400 patients to watch video scenarios and self-report on whether they would change physicians or … Download Citation
Related Resources From the Same Author(s)
Health plan … support on adverse drug events in the long-term care setting. … for long-term care residents with renal insufficiency.
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psnet.ahrq.gov/issue/invisible-disability-communication-patient-safety-and-dual-sensory-impairment-older-persons
July 01, 2019 - Patient inability to see and hear diminishes the effectiveness of their care experience, yet these … dual sensory impairment as a deterrent to safe, effective engagement of elderly patients in their care … communication-related factors on medication errors in public and private hospitals: a retrospective clinical … Impact of providing patients access to electronic health records on quality and safety of care … April 16, 2018
View More
See More About The Topic
Geriatrics
Nurse Care
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psnet.ahrq.gov/web-mm/poorly-advanced-directives
August 01, 2018 - at the end of life.( 3,6 ) The case presented is a common clinical scenario and one that could benefit … POLST orders translate a patient's general wishes for care into medical orders to provide or not provide … Patients or surrogates complete the form in discussion with their provider, and the patient or surrogate … The POLST form then accompanies the patient as he or she transfers between facilities or is discharged … patients, families, and providers on the same page before an acute event, to prevent confusion about the plan
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - a health care proxy or completed a living will prior to admission. … probability that after several days she would be
extubated and eventually restored to her baseline clinical … condition. … Elicit patients’ values and overall goals of care, and then present CPR or DNR as a way of matching … Thus, if a patient with a reversible condition refuses resuscitation, the physician
should ascertain
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - looking at diagnostic errors across a
disease or clinical condition. … The specialty experts are clinicians (e.g., gynecologists) who have expertise
in the specific 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
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psnet.ahrq.gov/issue/time-series-evaluation-improvement-interventions-reduce-alarm-notifications-paediatric
October 27, 2021 - monitoring can generate a large volume of alarm notifications that may not represent meaningful change in clinical … This article describes Plan-Do-Study-Act processes employed in the acute care cardiology unit of a … identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care … a tragic error
July 14, 2021
Emergency department monitor alarms rarely change clinical … tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical
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psnet.ahrq.gov/issue/when-medical-care-leads-harm-difficulty-finding-words-teachable-moment
September 23, 2017 - When medical care leads to harm- difficulty finding words: a teachable moment. … When medical care leads to harm- difficulty finding words: a teachable moment. … of health care professionals. … Effect of medication reconciliation at hospital admission on 30-day returns to hospital: a randomized clinical … aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical
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psnet.ahrq.gov/issue/health-system-redesign-cardiac-monitoring-oversight-optimize-alarm-management-safety-and
February 15, 2023 - alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or … December 21, 2017
The effect of providing staff training and enhanced support to care … homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement … Journal Article
Study
Clinician collaboration to improve clinical … tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical
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psnet.ahrq.gov/issue/safety-assurance-factors-ehr-resilience-safer-guides
January 10, 2007 - Health information technologies are seen to both contribute to and detract from health care safety . … This updated series of 8 toolkits offers best practices in foundational, infrastructure and clinical … Related Resources From the Same Author(s)
Department of Defense Health Care … January 10, 2007
Goals and Priorities for Health Care Organizations to Improve Safety … December 18, 2013
Health IT Patient Safety Action and Surveillance Plan.
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psnet.ahrq.gov/issue/er-doctor-discusses-role-ebola-patients-initial-misdiagnosis
October 15, 2014 - February 26, 2014
The impact of health care strikes on patient mortality: a systematic … September 29, 2010
Medication Safety: A Guide for Health Care Facilities. … The Topic
Emergency Departments
Patients
Emergency Medicine
Infectious Diseases
Clinical
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psnet.ahrq.gov/issue/your-hospital-really-safe-you-think-our-updated-hospital-safety-score-can-help-you-find-out
November 23, 2016 - Same Author(s)
Safety Is Personal: Partnering With Patients and Families for the Safest Care … November 23, 2016
Investigating Clinical Incidents in the NHS. … August 10, 2016
Rating hospitals by the stars: the feds' latest plan to measure quality … October 2, 2013
Why doesn't medical care get better when doctors rest more?