-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
April 22, 2004 - Key to
Understanding Health Care Systems
Ben-Tzion Karsh, Samuel J. … Medication
errors observed in 36 health care facilities. … Industrial Crisis Quarterly
1991;5:131–54.
19. Punnett L. … Patient care information systems and health
care work: a sociotechnical approach. … Qual Saf Health Care 2003;12(Suppl II):ii33–
ii38.
44.
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - That really brings value back to the health care system. … We have people coming back from other health care jobs. … Out of the Crisis. … 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.
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - Out of the Crisis. … 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. … That really brings value back to the health care system. … We have people coming back from other health care jobs.
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/opioid-chronic-pain-surveillance-report-3.pdf
June 01, 2022 - 1 found opioid dose
reduction or discontinuation
associated with increased risk of
mental health crisis … Association of dose tapering with overdose
or mental health crisis among patients
prescribed long-term … • Pain at the end of life
• Acute pain
• Pain due to active malignancy
• Pain due to sickle cell crisis … Association of dose tapering with overdose
or mental health crisis among patients
prescribed long-term … Adjuvant
interventions with opioids for vaso-
occlusive crisis in sickle cell disease: A
mixed treatment
-
psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
July 01, 2017 - events accumulated in a short period of time may signal a different kind of quality problem (e.g., life crisis … Malpractice law is intended to make health care safer. … provider, much less on fault by an individual health care provider. … deviation from care was at the system level. … We're going to continue to take care of patients."
-
psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - offices , and long-term care facilities . … increased a sense of value, respect, and empathy among healthcare teams, particularly during times of crisis … , primary care, and rapid response. … settings, including primary care, ambulatory surgery, nursing homes, and long-term care facilities. … span multiple care settings.
-
psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - anesthesia catastrophes, APSF may not have been viable had it not been for something else: a malpractice crisis … You're not going to be able to take care of your patients. … A year later, I came up for air and realized that we in health care could use this. … So from the very beginning our question was, does systems theory work in health care? … quality and patient safety in a care pathway.
-
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.
-
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.
-
psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - settings, including primary care, ambulatory surgery, nursing homes, and long-term care facilities. … span multiple care settings. … offices , and long-term care facilities . … increased a sense of value, respect, and empathy among healthcare teams, particularly during times of crisis … , primary care, and rapid response.
-
psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - Malpractice law is intended to make health care safer. … provider, much less on fault by an individual health care provider. … deviation from care was at the system level. … We're going to continue to take care of patients." … events accumulated in a short period of time may signal a different kind of quality problem (e.g., life crisis
-
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
-
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.
-
www.ahrq.gov/healthsystemsresearch/hspc-research-study/overlap-and-coordination.html
June 01, 2020 - and the Organization of Care. … In primary care, when CMS decided, CMMI specifically, to develop new models of payment for primary care … A federal stakeholder described the current opioid crisis as spurring similar interagency coordination … ’s not the whole primary care. … HRSA has the workforce part of primary care, but that’s just the workforce.
-
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].
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents
October 11, 2022 - , which is a team approach where the primary care clinician works with a behavioral health care manager … and psychiatrist to ensure patients receive the best care. … settings (or similar settings) compared with no screening or usual care. … J Health Care Poor Underserved . 2008;19(1):237-247. 22. … Ring the Alarm: The Crisis of Black Youth Suicide in America. Published 2020.
-
digital.ahrq.gov/sites/default/files/docs/citation/r01hs022542-hettinger-final-report-2020.pdf
January 01, 2020 - Cognitive Engineering for Complex Decision Making & Problem Solving in Acute Care - Final Report … Cognitive Engineering for Complex Decision Making & Problem Solving in Acute Care … expertise, key decisions and challenging activities
related to the provision of high-quality patient care … this verbiage.
7) Opioid Prescribing in the Emergency Department: Considering the worsening opioid
crisis … Participants were presented various scenarios requiring
a review of a patient’s care to be performed
-
effectivehealthcare.ahrq.gov/sites/default/files/cer-240-acute-pain-revised-comments.pdf
December 29, 2020 - Everyone
panicked because they wanted to blame
something on the Fentanyl crisis. … which contradicts their conclusions
concerning the centrality of medical
opioids in our public health crisis … much worse off
and the suffering they are enduring
unnecessarily because of this so called
opioid crisis … We
are also highly cognizant of the
devastating opioid crisis responsible for
the loss of hundreds … of thousands of lives
and the relationship of this crisis to
injudicious approaches to pain
management
-
hcup-us.ahrq.gov/reports/statbriefs/sb219-Opioid-Hospital-Stays-ED-Visits-by-State.pdf
October 31, 2016 - in opioid misuse,
use disorder, and overdoses, and to support State efforts to address the opioid crisis … Excluded are long-term care facilities such as
rehabilitation, psychiatric, and alcoholism and chemical … Beginning in 2012, long-
term acute care hospitals are also excluded. … , access to care, medical
conditions, procedures, patient populations, and other topics. … The reports use HCUP administrative
health care data.
-
hcup-us.ahrq.gov/db/nation/nrd/stats/MaskedStats_NRD_2015Q4_Dx_Pr_Grps.PDF
October 31, 2017 - DIAGNOSES W/O MEDICAL COMPLICATIONS 3,835 0.09%
789: NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE … THE BLOOD & BLOOD FORMING ORGANS W/O
CC/MCC
457 0.01%
808: MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS … & COAGUL W
MCC
2,320 0.05%
809: MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W
CC
7,046 … 0.16%
810: MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL
W/O CC/MCC
1,291 0.03%
811: RED