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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - partners in their ongoing care. … and uptake of care at home that would normally be provided in inpatient acute care settings. … and care were deeply disrupted. … is 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
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
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 … is 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 … and uptake of care at home that would normally be provided in inpatient acute care settings.
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Verbal Orders Verbal orders (VO) include all telephonic and face-to-face patient care orders that are … Many providers in community settings engage in daily on-site patient care and overnight coverage from … A Review of Verbal Order Policies in Acute Care Hospitals. … JOJ Nurse Health Care . 2017; 1(5):555575. Evans RS. … Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - ignition sources, with most fires occurring in oxygen-enriched environments (e.g., the OR, intensive care … unit, neonatal intensive care unit).( 8 )
While most OR fires in the United States are on-the-patient … The type of ignition source may result in smoke in the OR and potential harm to patients and health care … However, darkness is a potential safety hazard for patient care, since this makes it harder for team … Crisis checklists for the operating room: development and pilot testing.
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - pain The Case A middle-aged Black woman presented to the Emergency Department (ED) with sickle cell crisis … shown in Table 3 above, the patient was readmitted for abdominal pain secondary to sickle cell pain crisis … of care must be carefully managed. … hospitals, ambulatory primary care practices or specialty care practices, long-term care facilities, … UNC Health Care Guideline.
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - There are a variety of examples of these forcing functions in health care.( 5 ) In addition to the … In the heat of a crisis, or at the end of an anesthetic, the anesthesiologist might reach back to turn … One solution is to eliminate air flowmeters in most patient care settings. … Qual Saf Health Care. 2002;11:352-4.[ go to PubMed ] 6. Petty C. The anesthesia machine. … September 18, 2019
Inappropriate trust in technology: implications for critical care
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care … National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables. … National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables. … National Hospital Ambulatory Medical Care Survey: 2017 Emergency Department Summary Tables. … resource, therefore policymakers
and administrators should prioritize ED crowding as a public
health crisis
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - of the use of ultrasound guidance during central line insertion, 9 included in its Making Health Care … , and to debrief after complications occur, but may not be feasible or desirable in all settings of care … unit and a medical intermediate care unit using a customized line kit that had drape covers with labels … Crit Care . 2017;21(1):225. [ Free full text ] Shekelle PG, Dallas P. … May 16, 2022
Medical crisis checklists in the emergency department: a simulation-based
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - Multiple providers
were involved in her care (oncologist, radiation oncologist, primary care provider … The patient lived far away from the hospital where she
was receiving care. … effects, or tapering too
rapidly, resulting in flares of chronic disease or precipitation of adrenal crisis … Arthritis Care
Res (Hoboken). 2010;62:1515-1526. [go to PubMed]
13. … discharge and primary care follow-up.
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm based in Wyoming … IHI), where he has taken a role in teaching leadership skills
and promoting the engagement of health care … million-lives-campaign
https://psnet.ahrq.gov/issue/5-million-lives-campaign
https://psnet.ahrq.gov/issue/out-crisis … have delegated the quality and safety of care to the physicians, and possibly
the nurses. … the administration and the board
look at finances and facilities, and the doctors and nurses take care
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - Surveyors from State Department of Health
Can close units that do not meet standards of care. … USRDS may determine ESRD Network quality improvement projects and lead to development of standards of care … June 8, 2016
Changes in prevalence of health care-associated infections in U.S. hospitals … Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis … View More
See More About The Topic
Ambulatory Clinic or Office
Health Care
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - The patient was unable to tolerate the scan due to back pain, so the acute care nurse was instructed … Patient Safety Opioids and benzodiazepines are commonly used medications in the acute care setting. … Nurses are at the forefront of patient care in the acute care hospital setting and play a critical role … respiratory distress syndrome in intensive care units in 50 countries. … More
Related Resources
Team relations and role perceptions during anesthesia crisis
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - When her symptoms remained severe, she returned the following day to the urgent care center. … An appointment was made for her to follow-up with her primary care physician 3 days later in case symptoms … : flu, gastroenteritis, viral syndrome Stroke or cerebral ischemia Hypertensive crisis … WebM&M Cases
A "Reflexive" Diagnosis in Primary Care … Emergency Departments
Ambulatory Clinic or Office
Physicians
Emergency Medicine
Primary Care
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. … be difficult to identify in palliative care. … than in other types of care. … questionable benefit of life-sustaining crisis management and the clear expression of the
wishes of … of palliative care professionals.
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Background
Clinical training for health care professionals has historically relied heavily on learning … Because of the potential risks to patient and staff safety in the clinical
environment, special care … study in which non-clinician leadership and management had to respond to a simulated patient safety
crisis … Virtual_Simulation_in_Nursing_Education__A.9.aspx
https://psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care … AACN Adv Crit Care.
2016;27(1):56-61. [Free full text]
2. Sheen JJ, Goffman D.
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - than in other types of care. … questionable benefit of life-sustaining crisis management and the clear expression of the wishes of … of palliative care professionals. … Future care planning: a first step to palliative care for all patients with advanced heart disease. … Health Care Providers
Family Members and Caregivers
Palliative Care
View More
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - the role of physicians and nurses in optimizing quality and safety across the health care industry. … and families in choosing a nursing home, home health, or hospice care. … nursing, she was a research specialist for a California non-profit organization that helps children in crisis … to provide culturally competent care by using her fluency in four languages. … settings to improve health care delivery and outcomes.
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Review the drivers of speaking up in the health care environment. … Discrepant attitudes about teamwork among critical care nurses and physicians. … Crit Care Med. 2003;31:956-959. [go to PubMed]
5. Makary MA, Sexton JB. … Qual Saf Health Care. 2010;19:547-554. [go to PubMed]
8. Duhigg C. … Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - Commands, readbacks, and monitoring help bridge authority gradients and ensure the crisis-resistant performance … Care must be customized. … Transitions in care: studying safety in emergency department signovers. … Profiles in patient safety: emergency care transitions. … Emergency care transitions.
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - In short,
physicians must be at the top of their game when they are responsible for patient care. … that ensures the physical and emotional well being of the health care team. … These are more serious risks to quality patient care than failing to provide continuous care to
patients … Burnout and self-reported patient care in an internal medicine
residency program. … Work and Integrity: The Crisis and Promise of Professionalism in America. 2nd ed.