Results

Total Results: over 10,000 records

Showing results for "failures".

4901. Do clinicians know which of their patients have central venous catheters?: A multicenter observational study. | PSNet
      psnet.ahrq.gov/issue/do-clinicians-know-which-their-patients-have-central-venous-catheters-multicenter
      June 08, 2016 - Study Do clinicians know which of their patients have central venous catheters?: A multicenter observational study. Citation Text: Chopra V, Govindan S, Kuhn L, et al. Do clinicians know which of their patients have central venous catheters?: a multicenter observational study. Ann Intern…

4902. AHRQ’s Portrait of Sepsis Reveals Its Alarming Human Toll | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/blog/ahrqviews/portrait-of-sepsis.html
      September 01, 2024 - AHRQ Views: Blog posts from AHRQ leaders AHRQ’s Portrait of Sepsis Reveals Its Alarming Human Toll SEP 27 2024 By Robert Otto Valdez, Ph.D., M.H.S.A., and Pamela Owens, Ph.D. The human suffering caused by sepsis is shocking. New AHRQ analyses show that in 2021, more than 2 m…

4903. Interoperability | Digital Healthcare Research
      digital.ahrq.gov/health-care-theme/interoperability
      January 01, 2023 - Interoperability Development of SMART on FHIR Interoperable Clinical Decision Support for Emergency Department Patients with Pneumonia and Pilot Deployment into Novel Epic Electronic Health Record Environments Description This research will develop a SMART on FHIR version of a…

4904. Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention. | PSNet
      psnet.ahrq.gov/issue/listen-me-i-really-am-sick-patient-and-family-narratives-clinical-deterioration-and-during
      June 25, 2018 - Study Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention. Citation Text: Bucknall TK, Guinane J, McCormack B, et al. Listen to me, I really am sick! Patient and family narratives of clinical deterio…

4905. Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit? | PSNet
      psnet.ahrq.gov/issue/current-teaching-and-evaluation-methods-critical-care-medicine-has-accreditation-council
      February 23, 2022 - Study Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit? Citation Text: Chudgar SM, Cox CE, Que LG, et al. Current teaching and evaluation methods…

4906. Rates of Patient Safety Indicators in Belgian hospitals were low but generally higher than in US hospitals, 2016-18. | PSNet
      psnet.ahrq.gov/issue/rates-patient-safety-indicators-belgian-hospitals-were-low-generally-higher-us-hospitals-2016
      September 13, 2023 - Study Rates of Patient Safety Indicators in Belgian hospitals were low but generally higher than in US hospitals, 2016-18. Citation Text: Van Wilder A, Bruyneel L, Cox B, et al. Rates of Patient Safety Indicators in Belgian hospitals were low but generally higher than in US hospitals, 20…

4907. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. | PSNet
      psnet.ahrq.gov/issue/reengineered-hospital-discharge-program-decrease-rehospitalization-randomized-trial
      August 04, 2021 - Study A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Citation Text: Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87. Copy …

4908. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. | PSNet
      psnet.ahrq.gov/issue/impact-closed-loop-electronic-prescribing-and-administration-system-prescribing-errors
      November 13, 2009 - Study The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Citation Text: Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and admin…

4909. AHRQ's RED Toolkit Leads to Lower Readmissions, Better Care Transitions in Two Texas Hospitals | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/201420.html
      November 01, 2014 - AHRQ's RED Toolkit Leads to Lower Readmissions, Better Care Transitions in Two Texas Hospitals Search All Impact Case Studies November 2014 Two Texas hospitals have used AHRQ's Re-Engineered Discharge (RED) toolkit to help significantly reduce hospital readmissions and as a catalyst for additional progres…

4910. Keyser DJD et al. 2009 "Using health information technology-related performance measures and tool to improve chronic care." | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/keyser-djd-et-al-2009
      January 01, 2009 - Keyser DJD et al. 2009 "Using health information technology-related performance measures and tool to improve chronic care." Reference Keyser DJ, Dembosky JW, Kmetik K, et al. Using health information technology-related performance measures and tools to improve chronic care. Jt Comm J Qual Patient Saf …

4911. Ambulatory Safety and Quality Program: Enabling Quality Measurement through Health IT (R18) | Digital Healthcare Research
      digital.ahrq.gov/funding-mechanism/ambulatory-safety-and-quality-program-enabling-quality-measurement-through-health
      January 01, 2023 - Ambulatory Safety and Quality Program: Enabling Quality Measurement through Health IT (R18) Electronic health records and health care quality over time in a federally qualified health center. Citation Kern LM, Edwards AM, Pichardo M, et al. Electronic health records and health…

4912. Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients. | PSNet
      psnet.ahrq.gov/issue/just-what-doctor-ordered-missed-ordering-venous-thromboembolism-chemoprophylaxis-associated
      September 07, 2022 - Study Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients. Citation Text: Baimas-George MR, Ross SW, Yang H, et al. Just what the doctor ordered: missed ordering of venous t…

4913. Final Progress Report: Development Validation and Implementation of Customized Checklists for Safe Surgery (pdf file)
      www.ahrq.gov/sites/default/files/2024-03/gawande-report.pdf
      January 01, 2024 - Final Progress Report: Development Validation and Implementation of Customized Checklists for Safe Surgery Development Validation and Implementation of Customized Checklists for Safe Surgery Atul Gawande, MD, MPH, Principal Investigator Team Members: Alex Arriaga, MD, MPH, ScD Angela Bader, MD, MPH William Berry,…

4914. Informed Consent Document for Research at Memorial Hospital of RI (Brown University) | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/ahrq-funded-project-resources-archives/informed-consent-document-0
      January 01, 2023 - Informed Consent Document for Research at Memorial Hospital of RI (Brown University) Description Example consent form used in an AHRQ-funded project involving older adults. The study involves a focus group on medication management practices. Document Type Informed Consent Docume…

4915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50605/psn-pdf
      October 30, 2019 - Report focuses on risk to patients from ED errors. October 30, 2019 Palmer J. Patient Saf Qual Healthcare. Sept/Oct 2019. https://psnet.ahrq.gov/issue/report-focuses-risk-patients-ed-errors The pace of emergency care delivery can reduce reliability. This news story discusses an analysis of medical liability claims…

4916. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50714/psn-pdf
      December 04, 2019 - Suicidal patient slips through the cracks. December 4, 2019 Oakbrook Terrace, IL: Joint Commission: October 2019. https://psnet.ahrq.gov/issue/suicidal-patient-slips-through-cracks Inpatient suicide is increasing as a safety concern. This case analysis offers two levels of examination of a hypothetical patient sui…

4917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38001/psn-pdf
      July 14, 2010 - Safety skills for clinicians: an essential component of patient safety. July 14, 2010 Taylor-Adams S, Brodie A, Vincent CA. Safety Skills for Clinicians. J Patient Saf. 2008;4(3):141-147. doi:10.1097/pts.0b013e3181809631. https://psnet.ahrq.gov/issue/safety-skills-clinicians-essential-component-patient-safety Thi…

4918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38303/psn-pdf
      December 17, 2008 - Errors and analysis of errors. December 17, 2008 Mulligan MA, Nechodom P. Errors and analysis of errors. Clin Obstet Gynecol. 2008;51(4):656-65. doi:10.1097/GRF.0b013e3181899a5a. https://psnet.ahrq.gov/issue/errors-and-analysis-errors This article suggests elements of an effective error reduction program and provi…

4919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37237/psn-pdf
      December 15, 2011 - Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. December 15, 2011 Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70. https://psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and…

4920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35353/psn-pdf
      July 16, 2009 - Best-practice protocols: preventing adverse drug events. July 16, 2009 Weir VL. Best-practice protocols: preventing adverse drug events. Nurs Manage. 2005;36(9):24-30. https://psnet.ahrq.gov/issue/best-practice-protocols-preventing-adverse-drug-events This article reports on one hospital's use of failure modes and …