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psnet.ahrq.gov/issue/accuracy-practitioner-estimates-probability-diagnosis-and-after-testing
May 05, 2021 - Citation
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Treatment patterns and clinical … September 25, 2019
Implementation of the I-PASS handoff program in diverse clinical environments … Perception of the usability and implementation of a metacognitive mnemonic to check cognitive errors in clinical … July 2, 2014
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Ambulatory Clinic or Office … Educators
Primary Care
Clinical Misdiagnosis
Overtreatment
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psnet.ahrq.gov/issue/randomized-trial-reducing-ambulatory-malpractice-and-safety-risk-results-massachusetts
February 25, 2015 - Med Care. 2017;55(8):797-805. doi:10.1097/MLR.0000000000000759. … Also, time between test date and treatment plan was shorter in intervention sites. … December 21, 2017
Do work condition interventions affect quality and errors in primary … care? … Care Providers
Quality and Safety Professionals
Primary Care
Epidemiology of Errors and Adverse
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psnet.ahrq.gov/issue/open-disclosure-among-general-practitioners-second-victim-patient-safety-incident-cross
February 15, 2023 - Clinicians who are involved in patient safety incidents often continue to experience psychological or … September 27, 2023
In search of an international multidimensional action plan for second … September 19, 2016
The second victim phenomenon after a clinical error: the design and … evaluation of a website to reduce caregivers' emotional responses after a clinical error. … December 19, 2018
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Ambulatory Clinic or
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - first line treatment for degenerative disc
disease because this is a chronic, slowly progressive condition … The physician should have
considered whether the patient’s clinical symptoms fit with the
radiographic … relationships
they can foster, may contribute to delays in diagnosis because so much
focus in the clinical … foundational to collaborating with patients to develop a
safe and effective diagnosis and management plan … Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice
Guideline
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - It's our duty as health care providers to try to provide that care. … If I were interested in a particular condition, if I had cancer or heart disease, then I would probably … having computerized clinical systems, are you hopeful? … Where do you see this evolving as the world of clinical care and the way we capture what we do changes … Interview
In Conversation With...Amy Helwig about Health Plan
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psnet.ahrq.gov/issue/language-barriers-and-understanding-hospital-discharge-instructions
July 07, 2010 - Speak Different Languages
April 1, 2018
Do professional interpreters improve clinical … care for patients with limited English proficiency? … View More
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Hospitalized patients' understanding of their plan … of care. … June 29, 2011
Introduction of discharge plan to reduce adverse events within 72 hours
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psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging
June 16, 2011 - findings from administering the Safety Attitude Questionnaire (SAQ) to more than 10,000 providers in 203 clinical … The authors describe their findings with a goal that their tool will allow health care organizations … The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical … June 16, 2011
Implementation of the I-PASS handoff program in diverse clinical environments … in 11 centers across multiple economic strata: effect on care process measures.
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - distributing health care goods or services consumed by, or used on patients” and relevant financial … Suicide risk assessment should be
based on a synthesis of the overall clinical presentation, mental … /care
team should assess the patient’s capacity to leave without further care (i.e. understanding of … the clinical
situation, expressing a choice, ability to reason). … Care after an ED visit or acute medical hospitalization comprises a continuum of services;
these can
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psnet.ahrq.gov/issue/implication-covid-19-pandemic-patient-safety-rapid-review
March 09, 2022 - The COVID-19 pandemic created new risks and exacerbated existing risks across all areas of health care … This review examines how COVID impacted diagnostic , treatment, and care procedures in a systemic … October 7, 2020
Global Patient Safety Action Plan 2021-2030: Towards Eliminating Avoidable … Harm in Health Care. … View More
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Public Health
Infectious Diseases
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Another way that a facility can be cited or be required to implement a Plan of Correction is if it … plan and the medication administration record. … , they are obligated to plan for that care to include safe staffing levels. … Ron Ordona, DNP, FNP-BC, GS-C, WCC Health Sciences Assistant Clinical Professor Betty Irene Moore School … Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN Co-Editor-in-Chief, AHRQ’s Patient Safety Network (PSNet) Clinical
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - matter of
seconds.(1) While the fetus is often the provocateur of such chaos, changes in the mother’s condition … JCAHO issued several recommendations to health care organizations that care for pregnant women and
newborns … The first two concern conducting team training, clinical drills, and debriefings. … One
should endeavor to develop an implementation plan that is “win-win” and communicate that effectively—ie … The providers of bedside care are all trainees
with varying degrees of clinical experience enrolled
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - Minimal other clinical details were discussed. … None of the notes or clinical documentation from the referring hospital arrived with the patient other … a clinical escort) occurred over a 1-year period in Scotland (population 5.1 million).( 4 ) Of these … personnel are not adequate for the patient's condition.( 10,11 ) Once the patient arrives at the receiving … coordination and communication Receiving clinician is provided with full details of the patient's condition
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psnet.ahrq.gov/issue/combined-impact-medicares-hospital-pay-performance-programs-quality-and-safety-outcomes-mixed
December 08, 2021 - 2022
Measurement matters: changing penalty calculations under the hospital acquired condition … Interview
In Conversation With...Amy Helwig about Health Plan … July 10, 2024
Perspectives on Safety
Health Plan … health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical … Executives and Administrators
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Nurse Care
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psnet.ahrq.gov/node/49691/psn-pdf
September 01, 2013 - High-dose steroids were administered and the patient's condition rapidly improved. … She
ultimately returned to her baseline condition and was discharged home with her caretaker. … increase in many types of errors
soon after the transition.(6) This was despite the new EHR's advanced clinical … information identified as key by physicians includes medication data, laboratory data,
imaging files, clinical … Am J Manag Care. 2011;17:e121-e147.
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psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - Before leaving for the day, the primary intern reviewed the overnight plan with his senior resident and … The cross-cover intern reviewed this plan with her supervising resident, who agreed; she then wrote an … Christopher's Hospital for Children Philadelphia, PA Glenn Rosenbluth, MD Clinical Professor of Pediatrics … Real-world implementation of a standardized handover program (I-PASS) on a pediatric clinical teaching … December 19, 2018
Implementation of the I-PASS handoff program in diverse clinical environments
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psnet.ahrq.gov/node/864868/psn-pdf
March 27, 2024 - between different healthcare
levels, settings, or between team members or shifts handoffs within a hospital … when a patient moves between departments or when transitioning
between different care teams or when … during a patient’s transition
between locations or when care is handed off between shifts can enhance … Anna Satake PhD, MSN, GCNS, RN
Geriatric Clinical Nurse Specialist
Assistant Clinical Professor
Department … https://psnet.ahrq.gov/issue/applying-medications-transitions-and-clinical-handoffs-toolkit-rural-primary-care-clinic
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psnet.ahrq.gov/issue/parents-perceptions-medical-errors
April 27, 2010 - April 27, 2010
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … May 25, 2011
Measuring harm in health care: optimizing adverse event review. … May 3, 2017
Effect of a multifaceted clinical pharmacist intervention on medication safety … after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. … February 7, 2024
Implementation of the I-PASS handoff program in diverse clinical environments
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - poor communication amongst providers
Chronic condition(s)
Regardless of age, having a chronic condition … increases a patient’s risk for
polypharmacy to address the condition(s)
Data sharing/security
The … Shannan Takhar, PharmD, BCACP
Clinical Pharmacist, Ambulatory Care
Department of Pharmacy Services … Clinical consequences of polypharmacy in elderly. … Shared decision making: a model for clinical practice.
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Plan delaying surgery if a
corticosteroid injection has been given in the affected hand within 3 months … Choose an appropriate incision site and method (open vs. endoscopic) based on the
patient's condition … Carpal tunnel surgery: predictors of clinical outcomes
and patients’ satisfaction. … Clinical care redesign to improve value in carpal tunnel syndrome: a before-
and-after implementation … Management of Carpal Tunnel Syndrome Evidence-
Based Clinical Practice Guideline. May 18, 2024.
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psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
May 28, 2020 - care. … Devices in this class submit non-clinical, and sometimes clinical, evidence to demonstrate equivalence … , reduce errors and adverse events, and support innovation care practices. … enroll patients if the data is not routinely collected as a part of usual care. … The Action Plan highlights the enhancements the FDA has made- or is making- to their oversight of device