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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
September 01, 2021 - Publication No.
20(21)-0040-6-EF.
1
e
Introduction
Maternal mortality continues to be a public health crisis … Maternal near miss - towards a standard tool for monitoring quality
of maternal health care. … ACOG Committee Opinion No. 736: Optimizing Postpartum Care. … Triggers, bundles,
protocols, and checklists-what every maternal care provider needs to know. … critical care professions.
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www.ahrq.gov/sites/default/files/2025-02/shapiro-report.pdf
January 01, 2025 - Background
Emergency departments (EDs) are in the midst of a crowding crisis.(1-5) Although the
number … Hospital-Based Emergency Care: At the Breaking Point. … Care in the emergency department: how crowded is overcrowded? … Care Coordination. 2010 National Healthcare Quality
Report 2011. p. 167-78. … Early returns to different hospitals after emergency care [abstract].
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www.ahrq.gov/sites/default/files/2024-01/dierks-report.pdf
January 01, 2024 - Final Progress Report: Making Ambulatory Procedural Care Safer: STAMP-Based Risk Assessment and Redesign … Dierks, MD Beth Israel Deaconess Medical Center
Title of Project:
Making Ambulatory Procedural Care … from an
inpatient to an ambulatory care model. … However, the rapid and progressive conversion of procedural care
to an ambulatory setting can occur … Physical locations less fully equipped
for contingencies and often ‘remote’
from inpatient crisis
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/finalsummary.pdf
February 21, 2016 - • Transforming service delivery to promote quality of care. … care
plans. … support if they are faced with a personal
or family mental health, physical health, or other social crisis … The Child Core Set includes a wide range of topics, such as access to primary care, preventive
care … care, and family experiences with care.
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www.ahrq.gov/sites/default/files/publications/files/finalsummary.pdf
February 21, 2016 - • Transforming service delivery to promote quality of care. … care
plans. … support if they are faced with a personal
or family mental health, physical health, or other social crisis … The Child Core Set includes a wide range of topics, such as access to primary care, preventive
care … care, and family experiences with care.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf
March 01, 2018 - (A2)
52%
Staff in this unit work longer hours than is best
for patient care. … (A5R)
48%
We use more agency/temporary staff than is
best for patient care. … (A7R)
64%
We work in “crisis mode” trying to do too
much, too quickly. (A14R)
50%
11. … .
64% 9.73% 10% 52% 58% 64% 70% 76% 93%
A14
R
We work in “crisis mode” trying to do too
much, … We work in “crisis mode” trying to do too
much, too quickly.
50% 49% 1% 37% -25% 6% -5%
11.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2018hospitalsopsreport-rev0921.pdf
March 01, 2018 - (A2)
52%
Staff in this unit work longer hours than is best
for patient care. … (A5R)
48%
We use more agency/temporary staff than is
best for patient care. … (A7R)
64%
We work in “crisis mode” trying to do too
much, too quickly. (A14R)
50%
11. … .
64% 9.73% 10% 52% 58% 64% 70% 76% 93%
A14
R
We work in “crisis mode” trying to do too
much, … We work in “crisis mode” trying to do too
much, too quickly.
50% 49% 1% 37% -25% 6% -5%
11.
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www.ahrq.gov/ncepcr/reports/primary-care-research/references.html
January 01, 2024 - Inadequate reimbursement for care management to primary care offices. … Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care … Chronic care: making the case for ongoing care . … in care. … Addressing the primary care workforce crisis. Am J Manag Care. 2015 Aug;21(8):e452-e4.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
April 14, 2004 - It would
resolve what Burman et al. refer to as the “crisis in local IRB function” brought
on by the … The ecology
of medical care. N Engl J Med 1961;265:885–92.
4. … Med Care 2004;42(4 Suppl):III45–9.
5. Wolf LE, Croughan M, Lo B. … Crit
Care Med 2001;29(2):444–5.
10. Lux AL, Edwards SW, Osborne JP. … Crit Care Med 2001;29
(2):235–41.
14. Stair TO, Reed CR, Radeos MS, et al.
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www.ahrq.gov/sites/default/files/2024-09/studdert-report.pdf
January 01, 2024 - Negligent
care and malpractice claiming behavior in Utah and Colorado. … Med Care.
2000;38(3):250-60.
13 Studdert DM, Brennan TA. … The new medical malpractice crisis. N Eng J
Med 2003;348:2281-2284.
21. Marquis J, Rubin AJ. … Negligent
care and malpractice claiming behavior in Utah and Colorado. … Med Care 2000;38(3):250-
260.
41. LaBine SJ, LaBine G.
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www.ahrq.gov/ncepcr/reports/primary-care-research/results.html
January 01, 2024 - care. … This includes a Care Management Information Brief and a Care Management in Primary Care Implementation … care. … crisis—that is, decreasing numbers of medical school graduates entering a family medicine or internal … is to explore methodologies for identifying patients at highest risk of opioid overdose, a national crisis
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Patey.pdf
January 01, 2004 - social skills such as teamworking).1 There is increasing
awareness of a similar pattern in health care … markers for good practice
• Confirms roles and responsibilities of
team members
• Discusses care … Respondents thought it would not be possible to use
the system when personally directing patient care … Anaesth & Int Care 1993;
21:506–19.
4. O’Connor P, Höermann H-J, Flin R, et al. … Anesthesia crisis
resource management training: teaching
anesthesiologists to handle critical incidents
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
January 01, 2004 - The transition between levels of care
within the acute care setting or across the continuum of care … unit (ICU) to a lower level of care,
resulting in Addisonian crisis and subsequent death. … • Move the patient to a higher level of care for more careful monitoring. … A report of
the Committee on Quality of Health Care in America,
Institute of Medicine. … Making health care safer: a critical analysis of patient
safety practices.
-
www.ahrq.gov/sites/default/files/2024-07/congdon-magilvy-report.pdf
January 01, 2024 - Examples of the indicators of
quality care in nursing homes include indicators of physical care, such … , Alzheimer’s care, hospice, or respite care). … Quality and Substandard Care. … hours had fewer citations for Care Quality and for
Substandard Care. … The crisis nature of health care transitions for
rural older adults.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
April 07, 2008 - Fourth, it can cause disruption in the patient care
unit. … Simulation-based
training in anesthesia crisis resource management
(ACRM): A decade of experience. … Medical
team training programs in health care. … Qual Saf Health Care 2004; 13: i51-i56.
15. Northam G. … Qual Saf Health
Care 2003; 12: ii2-ii7.
23. Marx DA, Slonim AD.
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www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
January 01, 2024 - ontology for use in characterizing the
relationship between healthcare facilities (the “environment of care … The purposes of this model-based system would be to help in making decisions in a time of
crisis with … Centers for Disease Control and Prevention – Guidelines for Environmental Infection Control in
Health-care … there are significant potential benefits in
understanding better the role that the ‘environment of care … In particular, it is
important that the environment of care is well maintained and adequately supports
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
February 09, 2005 - Each facility
had a unique history and culture with regard to warfarin care. … The regional crisis involving the supply of pharmacists and pressures on
administrators to implement … To what extent can the results be generalized to other patient
care settings? … Qual Saf Health Care 2002;11:69–75.
6. Ash J. … Qual Manag Health Care 1998;6(4):15–
28.
11. McMahan D, Smith D, Carey M, et al.
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www.ahrq.gov/sites/default/files/2024-07/gallagher5-report.pdf
January 01, 2024 - do not reflect physician incompetence but rather reflect
system failures or situations in which the care … A Statement of Understanding between the Foundation for Health Care Quality, the
neutral body designated … The WMC’s
Reduction of Medical Error (ROME) Committee came to the Foundation for Health Care Quality … In Washington, we worked with State
Representative Eileen Cody, who chairs the House Health Care and … legislature in March
2020 but was vetoed by the governor as the state budgetary impact of the COVID-19 crisis
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Dingley_14.pdf
February 06, 2008 - • Phase 1 focused on two settings: the Medical Intensive Care Unit (MICU) and the Acute
Care Unit … on behavioral health units: an Adult Psychiatric Unit, an Adolescent
Psychiatric Unit, and an Acute Crisis … planning, patient safety issues, cost and quality of care issues, setting daily goals of
care, and … In a study of
multidisciplinary rounding focused on daily care goals in intensive care, the results … care nursing.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
July 28, 2016 - ]
Accountable care organization with care
management or transition care
[high-risk-care management … , transitional care to reduce readmissions, etc.]
Medicaid managed care organizations [high-risk-care … [medication reconciliation efforts] • [community mobile crisis teams]
• [whole‐person needs assessment … ACCESS TO AMBULATORY CARE
No regular source of care
Difficulty with transportation to medical care … to Readmissions County residents
suffering from acute or serious mental disorders or an emotional crisis