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psnet.ahrq.gov/node/865413/psn-pdf
March 27, 2024 - Ransomware attacks can impact any component
of care delivery and operational functions. … How
do we continue to deliver safe and quality care without technology? That is not an IT issue. … This is crisis leadership,
and they are going to have to make decisions that the FBI is not going to … In law enforcement,
whenever there is an operational issue or crisis, we create an after-action report … IT allows the clinical staff
to deliver patient care efficiently.
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psnet.ahrq.gov/node/49416/psn-pdf
September 01, 2003 - Workforce issues have been an enormous concern in recent years as nursing shortages
reach crisis proportions … general care units. … Crit Care
Med. 1997;25:1289-1297.[ go to PubMed ]
4. … Critical Care Nursing Fact Sheet. … American Association of Critical-Care Nurses. [ go to related site ]
7.
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psnet.ahrq.gov/primer/responding-patient-safety-events
October 18, 2023 - Background Patient safety events that occur in health care facilities require prompt action to ensure … Based on the investigation, if harm is deemed to be due to inappropriate care, the circumstances and … If following the investigation, the adverse event is determined to be the result of substandard care, … it is important that clinicians and the health care organization apologize to the patient and their … supervisors and fellow team members, trained peer supporters and risk management resources to provide crisis
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psnet.ahrq.gov/primer/high-reliability
January 29, 2020 - The concept of high reliability is attractive for health care, due to the complexity of operations and … Sometimes people interpret high reliability as meaning effective standardization of health care processes … Thus, people in HROs know that in a crisis or emergency the person with greatest knowledge of the situation … AHRQ has outlined practical strategies for health care organizations aiming to become highly reliable … High-reliability health care: getting there from here.
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. … An Endocrinology consultation was obtained due to a suspicion for adrenal crisis associated with chronic … persistent hypotension, she was transferred to the MICU where she was treated for putative adrenal crisis … Measuring diagnostic errors in primary care: the first step on a path forward. … Comment on "Types and origins of diagnostic errors in primary care settings".
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. … An
Endocrinology consultation was obtained due to a suspicion for adrenal crisis associated with chronic … persistent hypotension, she was transferred to the
MICU where she was treated for putative adrenal crisis … Comment on "Types and origins of diagnostic errors in primary care settings".
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psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
January 01, 2020 - should be able to:
Recognize suicide as a major public health problem and the critical role of primary care … settings
Understand how to assess suicide risk in the primary care setting and how to triage high-risk … The primary care doctor was not notified of the patient's behavior at the time of the phone call.
4 … ED-SAFE Screen)
Review these screening tool results before patient leaves appointment
For suicidal crisis … Suicidal ideation in primary care.
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psnet.ahrq.gov/node/49428/psn-pdf
January 01, 2004 - s primary care physician—who has a better understanding of the patient? … immediate life threat occurs, it may be prudent to treat the
patient and continue discussions when the crisis … In end-of-life care, the patient's wishes remain paramount.
Albert W. … A look into the nature and causes of human errors in the intensive
care unit. … An alternative strategy for studying adverse events in medical
care.
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - SPOTLIGHT CASE
Some Patients Can't Wait: Improving Timeliness of Emergency Department Care … Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. … Communication failures are distributed equally among all phases of surgical care. … A QMP may initiate and complete the care episode in this area. … resource; therefore, policymakers and administrators should prioritize ED crowding as a public health crisis
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - and improving health care quality and safety. … fields into health care. … Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management … Some unintended consequences of information technology in health care: the nature of patient care information … Ambulatory Care
Health Care Executives and Administrators
Information Professionals
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psnet.ahrq.gov/node/33812/psn-pdf
August 01, 2016 - BPP: I believe that new information technologies will make a significant improvement in patient care … But the care context is different. … RW: You've noted that most care occurs in small offices. … Spain has a system of
universal free health care. Hospitals are very hierarchical. … But the major economic crisis
we've had since 2007 has cut the health budget, and this has affected
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - may
negatively impact their experiences of care, including worse reports of quality of care, further … -2023
https://psnet.ahrq.gov//#8
https://psnet.ahrq.gov/issue/woman-works-end-black-maternal-health-crisis-after-daughter-dies-after-giving-birth … https://psnet.ahrq.gov/issue/woman-works-end-black-maternal-health-crisis-after-daughter-dies-after-giving-birth … Perinatal Care (SPPC-I)
AHRQ Safety Program in Perinatal Care – Toolkits to Reduce Hypertension in … Health care engagement and follow-up after perceived discrimination
in maternity care.
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - and care were deeply disrupted. … We’ve seen sizeable shifts to alternative models of care and locations of care delivery, with the use … emblematic of what I would hope our collaboration and daily work in safety looks
like every day, “crisis … IHI’s agility and ability to pivot, innovate, and
spread improvements during both conventional and crisis … The
second area is meaningful patient and family engagement in their own care, and all aspects of care
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - focus was on short-term actions that could be taken at an institutional level to address the staffing crisis … We can’t just leapfrog over those who are delivering care and then say we care about patient care. … Missed nursing care refers to necessary nursing care that is not completed, often because nurses do … December 22, 2008
The silence of the unblown whistle: the Nevada hepatitis C public health crisis … Missed Care
View More
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - spinal
block causing severe hypotension, right ventricular ischemia, and a pulmonary hypertensive crisis … The patient was transferred
to the intensive care unit and was weaned off ECMO after five days. … She was extubated after nine days in
intensive care and survived without any neurological sequelae. … Recently, there has been a push for hospitals to develop a cardio-obstetrics team to coordinate care … Am J Respir Crit Care Med. 2002;165(3):341-344. [Free full text]
7.
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - support protocol,
spontaneous circulation returned and the patient was transferred to the intensive care … The fasciotomy wounds were slow to heal and required ongoing complex care. … In a crisis situation, particularly one in
which large volumes of fluids or vasoactive medications are … The initial care of casualties. Am Pract Dig Treat. 1946;1:183. [go to PubMed]
3. … Crit Care Nurse. 2010;30:e1-e7. [go to PubMed]
4. Luck RP, Haines C, Mull CC. Intraosseous access.
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - and obstetric care, and approaches to improve patient safety
during labor and delivery. … Health Care
Manag (Frederick). 2020;39(3):122-127. [Available at]
26. Nelson D. … Pediatr
Emerg Care. 2007;23(7):498-503. [Available at]
27. Stewart NH, Arora VM. … When policy meets reality: the new 18-hour on-call shift policy and the Israeli anesthesia workforce
crisis … The anesthesia workforce crisis revisited. Anesth Analg. 2023;136(2):227-
229.
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - in the patient’s care. … Establish and clarify protocols for care coordination across services. … The opioid crisis: treating our nation’s veterans. University of Maryland School of Nursing. … https://www.nursing.umaryland.edu/media/son/academics/professional-education/The-Opioid-Crisis-Treating-Our-Nations-Veterans-pdf.pdf … Med Care. 2011;49(4):393-396. doi:10.1097/MLR.0b013e318202aa27
U.S.
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - and obstetric care, and approaches to improve patient safety during labor and delivery. … Health Care Manag (Frederick ). 2020;39(3):122-127. [ Available at ] Nelson D. … Pediatr Emerg Care . 2007;23(7):498-503. [ Available at ] Stewart NH, Arora VM. … When policy meets reality: the new 18-hour on-call shift policy and the Israeli anesthesia workforce crisis … The anesthesia workforce crisis revisited.
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - Out of the Crisis. … Washington,
DC: Committee on Quality of Health Care in America, Institute of Medicine. … From triple to quadruple aim: care of the patient requires care of the provider. … Address safety across the entire care continuum
6. Support the health care workforce
7. … Partner with patients and families for the safest care
8.