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psnet.ahrq.gov/node/47957/psn-pdf
April 24, 2019 - A really stupid mistake: it does feel like a cop out to
blame my error on human frailty, but I'm afraid that's
exactly what it was.
April 24, 2019
Maskell G. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm
afraid that's exactly what it was. BMJ. 2019;365:l1617. doi:…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2021-childhcahps-infographic.pdf
January 01, 2021 - 2021 CAHPS Child Hospital Survey Database Chartbook Executive Summary
2021 Child Hospital Survey Database
The pilot year 2021 Consumer Assessment of Healthcare
Providers and Systems (CAHPS®) Child Hospital Survey
Database includes 5,858 survey responses voluntarily
submitted by 11 hospitals.
High Scoring
Meas…
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psnet.ahrq.gov/node/43438/psn-pdf
February 23, 2018 - Safety-I and Safety-II: The Past and Future of Safety
Management.
February 23, 2018
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
https://psnet.ahrq.gov/issue/safety-i-and-safety-ii-past-and-future-safety-management
Historically, the approach to patient safety has been more reacti…
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digital.ahrq.gov/2020-year-review/research-dissemination
January 01, 2020 - Research Dissemination
Dissemination of research findings is an important part of the research process, passing on the benefits to other researchers, healthcare providers and systems, vendors, policymakers, patients, and other stakeholders in order to support replication of successful …
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www.ahrq.gov/hai/cusp/modules/understand/index.html
July 01, 2018 - Understand the Science of Safety
The Understand the Science of Safety module of the CUSP Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will provide a higher quali…
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digital.ahrq.gov/principal-investigator/xiong-glen
June 09, 2020 - Xiong, Glen
Asynchronous telepsychiatry interviewer training recommendations: A model for interdisciplinary, integrated behavioral health care.
Citation
Parish MB, Gonzalez A, Hilty D, Chan S, Xiong G, Scher L, Liu D, Sciolla A, Shore J, McCarron R, Kahn D, Iosif AM, Yellowlee…
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psnet.ahrq.gov/node/866106/psn-pdf
June 12, 2024 - Artificial intelligence and healthcare: a journey through
history, present innovations, and future possibilities.
June 12, 2024
Hirani R, Noruzi K, Khuram H, et al. Artificial intelligence and healthcare: a journey through history, present
innovations, and future possibilities. Life (Basel). 2024;14(5):557. doi:10.…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-7-professionalism.pdf
September 01, 2015 - practices you observe, confirm that the practice
has agreed to this (this agreement will often be discussed … In addition to many of the items
discussed above, maintaining professionalism during virtual facilitation … The
PF discussed this further with the consultant after the initial introduction.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/mental-illness-disparities_research-protocol.pdf
July 01, 2015 - Research Protocol: Disparities Within Serious Mental Illness
Evidence-based Practice Center
Project Title: Disparities within Serious Mental …
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effectivehealthcare.ahrq.gov/sites/default/files/dementia-horizon-scan-high-impact-1406.pdf
February 01, 2015 - DEMENTIA INCLUDING ALZHEIMER'S #04
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 04: Dementia (Including Alzheimer’s
Disease)
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
June 05, 2008 - News Media and Health Care Providers at the Crossroads of Medical Adverse Events
News Media and Health Care Providers at the
Crossroads of Medical Adverse Events
Pamela Whitten, PhD; Mohan J. Dutta, PhD; Serena Carpenter, PhD; Graham D. Bodie
Abstract
In 2005, Indiana Governor Mitch Daniels issued an executi…
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effectivehealthcare.ahrq.gov/sites/default/files/s44.pdf
October 01, 2007 - effects are manifested within days or months, influ-
ences the perceived appropriateness of PRTs, as is discussed … This is analogous to limitations on generalizabil-
ity of analyses using instrumental variables, discussed
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - Other PSNet WebM&M cases have discussed a patient with glioblastoma whose
physicians prematurely closed … At least two WebM&M cases previously discussed in PSNet
have demonstrated the potential negative consequences
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - globally,33 errors related to vasopressor administration through continuous infusions
are infrequently discussed … We previously
discussed (see section on Vasopressor Administration & Monitoring above) how norepinephrine
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/030-hand-hygiene-webinar-slides-notes.docx
October 01, 2024 - Disease Control and Prevention (CDC) or the World Health Organization (WHO), both of which will be discussed … SAY:
As discussed earlier, there are many indications for hand hygiene in the healthcare setting during
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - Appendix C ) of what the event reviewer(s) believe are the contributing factors (to be proposed and discussed … For each critical contributing factor determined in the CC meeting, solutions are discussed, responsibility
-
www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
January 01, 2024 - practices using the Institute for Safe Medication
Practices (ISMP) tool, and hospitals shared and discussed … participated in annual Patient
Safety Consortium conferences, at which hospital representatives and experts discussed
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
March 15, 2016 - The documentation and coding issues and suggested actions discussed in this section are relevant
not … In the following section, issues specific to the PDIs are
discussed, including issues and actions specific
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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 - Implementation
Issues discussed by the medication subcommittee included the following:
• What do … The patient died shortly after the naloxone was
administered, but the RCA never discussed the potential
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - globally, 33 errors related to vasopressor administration through continuous infusions are infrequently discussed … We previously discussed (see section on Vasopressor Administration & Monitoring above) how norepinephrine