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Showing results for "failures".

  1. Effect of hospital readmission reduction on patients at low, medium, and high risk of readmission in the Medicare population. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/health-information-technology-heart-failure-care/citation/effect
    January 01, 2023 - Effect of hospital readmission reduction on patients at low, medium, and high risk of readmission in the Medicare population. Citation Blecker S, Herrin J, Kwon JY, Grady JN, Jones S, Horwitz LI. Effect of hospital readmission reduction on patients at low, medium, and high risk of readmission in the M…

  2. Cardio-Hit Phase II - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/cardio-hit-phase-ii/final-report
    January 01, 2023 - Cardio-Hit Phase II - Final Report Citation Kmetik K. Cardio-Hit Phase II - Final Report. (Prepared by American Medical Association under Grant No. R18 HS017160). Rockville, MD: Agency for Healthcare Research and Quality, 2010. PDF Cardio-Hit Phase II - Final Report The findin…

  3. Changing patient care orders from paper to computerized provider order entry-based process. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/rural-iowa-redesign-care-delivery-ehr-functions/citation/changing-patient-care
    January 01, 2023 - Changing patient care orders from paper to computerized provider order entry-based process. Citation Brokel JM, Ward MM, Wakefield DS, et al. Changing patient care orders from paper to computerized provider order entry-based process. Comput Inform Nurs 2012 Aug;30(8):417-25. Link http://www.nc…

  4. The e-Coach technology-assisted care transition system: a pragmatic randomized trial. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-enhanced-care-transition-support-complex/citation/e-coach
    January 01, 2023 - The e-Coach technology-assisted care transition system: a pragmatic randomized trial. Citation Ritchie CS, Houston TK, Richman JS, et al. The E-Coach technology-assisted care transition system: a pragmatic randomized trial. Transl Behav Med 2016 Sep;6(3):428-37. PMID: 27339715. Link https://ww…

  5. Multitasking and silent electronic health record use in ambulatory visits. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/engaging-diverse-patients-using-online-patient-portal/citation/multitasking
    January 01, 2023 - Multitasking and silent electronic health record use in ambulatory visits. Citation Ratanawongsa N, Matta GY, Lyles CR, et al. Multitasking and silent electronic health record use in ambulatory visits. JAMA Intern Med 2017 Sep 1;177(9):1382-5. PMID: 28672379. Link https://www.ncbi.nlm.nih.gov/…

  6. The E-Coach transition support computer telephony implementation study: Protocol of a randomized trial. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-ivr-enhanced-care-transition-support-0
    January 01, 2023 - The E-Coach transition support computer telephony implementation study: Protocol of a randomized trial. Citation Ritchie C, Richman J, Sobko H, et al. The E-Coach transition support computer telephony implementation study: Protocol of a randomized trial. Contemp Clin Trials 2012 Nov;33(6):1172-9. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43714/psn-pdf
    December 17, 2014 - ER doctor discusses role in Ebola patient's initial misdiagnosis. December 17, 2014 Dunklin R, Thompson S. Dallas Morning News. December 6, 2014. https://psnet.ahrq.gov/issue/er-doctor-discusses-role-ebola-patients-initial-misdiagnosis This news article reports on the widely publicized delayed diagnosis of Ebola a…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845658/psn-pdf
    June 08, 2023 - Simulation Articles of Influence. June 8, 2023 Society for Simulation in Healthcare. 2017-2023. https://psnet.ahrq.gov/issue/simulation-articles-influence Simulation can be used to reveal teamwork coordination gaps and latent factors that contribute to failure. This article collection has been curated by experts i…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39643/psn-pdf
    December 21, 2014 - A systematic quantitative assessment of risks associated with poor communication in surgical care. December 21, 2014 Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg. 2010;145(6):582-8. doi:10.1001/archsurg.2010.105. http…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72484/psn-pdf
    November 18, 2020 - Management of Operating Room Critical Events. November 18, 2020 Hannenberg AA, ed. Anesthesiol Clin. 2020;38(4):727-922. https://psnet.ahrq.gov/issue/management-operating-room-critical-events Anesthesiology critical events are uncommon, and yet they have great potential for harm. This special issue focuses on mana…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866357/psn-pdf
    July 24, 2024 - People’s Experiences of Diagnosis. July 24, 2024 People’s Experiences Of Diagnosis. London, England: National Voices; June 2024. https://psnet.ahrq.gov/issue/peoples-experiences-diagnosis The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report explores the diagnosti…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35479/psn-pdf
    June 14, 2011 - Implementing root cause analysis in an area health service: views of the participants. June 14, 2011 Middleton S, Walker C, Chester R. Implementing root cause analysis in an area health service: views of the participants. Aust Health Rev. 2005;29(4):422-8. https://psnet.ahrq.gov/issue/implementing-root-cause-analy…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36564/psn-pdf
    January 12, 2011 - Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010. January 12, 2011 Crane J, Crane FG. Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010. Hosp Top. 2006;84(4):3-8. http…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841199/psn-pdf
    December 07, 2022 - Press Play on Safety Conversations. December 7, 2022 Healthcare Excellence Canada. 2022. https://psnet.ahrq.gov/issue/press-play-safety-conversations After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45478/psn-pdf
    October 26, 2016 - Core principles of quality improvement and patient safety. October 26, 2016 Bartman T, McClead RE. Core Principles of Quality Improvement and Patient Safety. Pediatr Rev. 2016;37(10):407-417. https://psnet.ahrq.gov/issue/core-principles-quality-improvement-and-patient-safety This review discusses key patient safet…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41641/psn-pdf
    August 29, 2012 - Patient safety and quality improvement: an overview of QI. August 29, 2012 Schriefer J, Leonard M. Patient safety and quality improvement: an overview of QI. Pediatr Rev. 2012;33(8):353-9; quiz 359-60. doi:10.1542/pir.33-8-353. https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-overview-qi This c…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44550/psn-pdf
    September 30, 2015 - Infections associated with reprocessed flexible bronchoscopes. September 30, 2015 FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015. https://psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes Use of incompletely cleaned medical devices has b…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46018/psn-pdf
    January 16, 2019 - Rethinking Patient Safety. January 16, 2019 Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541. https://psnet.ahrq.gov/issue/rethinking-patient-safety The National Health Service (NHS) has been a leader in patient safety work for close to two decades. This book draws from a large-scale impro…

  19. Module 8—Injection Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/nursing-home/resources/module-8-injection-safety.html
    May 01, 2022 - Module 8—Injection Safety Resource: Module 8—Injection Safety This module provides an overview of injection safety, along with a review of recommended practices and the consequences of failure to follow safe injection practices. At the conclusion of this module, participants will be able to: 1. define injec…

  20. TeamSTEPPS Coaching Feedback Form (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-coaching-feedback-form.pdf
    June 02, 2025 - TeamSTEPPS Coaching Feedback Form Coaching Feedback Form INSTRUCTIONS While observing the scripted coaching practice exercise, use this form to document the demonstrated competencies of the designated coach. The coach works through the designated issue with the team member, the team member acts out the particula…
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