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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - communicates to a nurse
assigned to locate an appropriate bed for the patient (i.e., on the correct clinical … knowledge of, the patient's history or the
treatment plan.) … activated by the inpatient physician to ensure the orders are
appropriate for the current clinical … plan. … clinical information system. eJournal
of Health Informatics. 2011;6:e5.
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - 8.1%, with 19% to 67% of these errors causing potential patient harm.(2-5)
The American Society of Clinical … /psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
viewed at any time by any health care … that may or may not be properly
propagated to remainder of plan).(1) All staff need to be constantly … use of standardized
electronic treatment plans can promote safe ordering workflows, but all health care … Neuss MN, Gilmore TR, Belderson KM, et al. 2016 Updated American Society of Clinical
Oncology/Oncology
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - An example would be an unexpected transfer to an intensive care unit or the use of a drug that is an … care. … In their National Action Plan to Advance Patient Safety , AHRQ and the Institute for Healthcare Improvement … August 28, 2024
Perspectives on Safety
Health Plan … Ambulatory Clinic or Office
Health Care Providers
View More
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - care. … In their National Action Plan to Advance Patient Safety , AHRQ and the Institute for Healthcare Improvement … An example would be an unexpected transfer to an intensive care unit or the use of a drug that is an … February 26, 2025
Perspectives on Safety
Health Plan … Ambulatory Clinic or Office
Health Care Providers
View More
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - EMS clinical data based on a national EMS data standard, the National EMS Information System, or NEMSIS … So, for example, using the clinical electronic patient care record data, let's say that we saw something … Remle Crowe: All of the clinical data that gets collected, independent of EPCR [electronic patient care … the quality of care, or how safe the care delivered was, or whether patient safety events are happening … they're going to be following improvement science principles and doing these rapid tests of change, PDSA [plan
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical … condition for errors and harm. … tools were useful, none were subjected to rigorous research that captured key elements of context, clinical … interprofessional care for community-dwelling patients identified as high risk
for readmission or death … , there were no differences between the
virtual ward and usual care in readmissions or death.
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - expected to have similar hospital resource use because the patients within each group
have the same condition … Using this framework, "death in low-mortality DRG" would score highly on clinical importance and (in … Reviewing deaths in low-mortality DRGs falls within the norm of clinical practice insofar as it is a … moderately expensive diagnostic process that targets a relatively unlikely condition. … Credibility and
buy-in with
clinicians
The detection strategy has credibility (e.g., hard clinical
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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - the hospital to a home-based or community
care environment. … living or residential care facility. … encounter within the 90 days prior to the start of care
or within 30 days after the start of care, … condition is expected to
improve in a reasonable time. … Association of a bundled hospital-at-home and 30-day
postacute transitional care program with clinical
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psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
November 30, 2022 - Related Resources From the Same Author(s)
Complexity and challenges of the clinical … , 2022
Clinician-identified problems and solutions for delayed diagnosis in primary care … December 16, 2020
Diagnosis of physical and mental health conditions in primary care … December 30, 2014
WebM&M Cases
A Seasonal Care Transition … January 1, 2009
View More
See More About The Topic
Ambulatory Clinic or
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - Clinical context is also very important. … (e.g., transfer to the intensive care unit), inefficiencies in care, and delays in diagnosis or treatment … The handover provides information about the patients' clinical course and condition, as well as what … clinical status). … Have a formal plan for handover at change of shift and change of service
2.
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or … With expanded use, there has also been an increase in how telehealth technologies are used in clinical … the onset of the COVID-19 pandemic, which
reduced the time and opportunity for healthcare operations or … , (2) very limited physical examinations, omitting key modalities such as
auscultation and private or … inaccessible areas of the body, (3) reliance on patients and their families to
measure vital signs or
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - consulted and
concluded that the patient's symptoms were likely benign positional vertigo (a common condition … visits or resource
utilization. … studies have
correlated translation with clinical outcomes. … for improving communications
during clinical visits. … of pharmaceutical products or medical devices.
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psnet.ahrq.gov/issue/accidental-iatrogenic-pneumothorax-hospitalized-patients
April 03, 2005 - Med Care. 2006;44(2):182-186. … February 6, 2008
Risk from delayed or missed care and non-COVID-19 outcomes for older … December 9, 2020
Competition and health plan performance: evidence from health maintenance … Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical … May 1, 2015
Clinical impact and frequency of anatomic pathology errors in cancer diagnoses
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - communicates to a nurse assigned to locate an appropriate bed for the patient (i.e., on the correct clinical … knowledge of, the patient's history or the treatment plan.) … activated by the inpatient physician to ensure the orders are appropriate for the current clinical status … plan. … Intensive care unit nurse workflow during shift change prior to the introduction of a critical care clinical
-
psnet.ahrq.gov/issue/communicating-patients-about-medical-errors-review-literature
December 23, 2008 - Download Citation
Related Resources From the Same Author(s)
Health plan … October 11, 2023
Effect of a multifaceted clinical pharmacist intervention on medication … safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial … March 17, 2021
Primary care providers' opening of time-sensitive alerts sent to commercial … November 15, 2011
Nurse-physician communication in the long-term care setting: perceived
-
psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - No heart or lung abnormalities were noted on exam. … signs as symptoms to pneumonia ultimately found to be caused by another condition. … A mindful approach to patient care requires full evaluation of all serious abnormalities encountered, … Semin Respir Crit Care Med. 1995;16:269-278. [Available at] 10. … View More
See More About The Topic
Emergency Departments
Health Care
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psnet.ahrq.gov/node/49847/psn-pdf
November 01, 2018 - Before leaving for the day,
the primary intern reviewed the overnight plan with his senior resident … The cross-cover intern reviewed this plan with her supervising resident, who agreed; she then
wrote … management plans.(7,8) In addition, resident handoff documents more frequently included key elements
like clinical … 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
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psnet.ahrq.gov/node/49547/psn-pdf
October 01, 2007 - main hospital building, hospitals must provide screening and
emergency stabilization for any medical condition … or treatment.(4,5) While the actual care required is not dictated, the government does
expect the hospital … in-hospital cardiac arrests will occur to visitors or staff either within its non-core clinical
areas … Traditionally, code teams must roll
cumbersome defibrillation equipment from distant clinical areas … Adams, MD COL, MC, US Army Chief, Department of Clinical Investigation William Beaumont
Army Medical
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - After losing 15 pounds in less than 2 months, she visited her primary care physician. … Puzzled, the lymphoma specialist requested a second pathology opinion from a tertiary care center with … January 8, 2016
Laboratory medicine handoff gaps experienced by primary care practices … January 1, 2004
View More
See More About The Topic
Ambulatory Care … Health Care Providers
Safety Scientists
Pathology and Laboratory Medicine
Diagnostic Test
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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - (e.g., transfer to the intensive care unit), inefficiencies in care, and delays in diagnosis or treatment … The handover provides information about the patients' clinical course and condition, as well as what … clinical status). … Have a formal plan for handover at change of shift and change of service
2. … or very little investment made in trying to improve that care transition.