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Learning Health Systems for Patient Safety | PSNet

psnet.ahrq.gov/perspective/learning-health-systems-patient-safety

February 26, 2025 - health system (i.e., a group of one or more healthcare organizations, such as physician practices, hospitals … The organization I am in right now is a 40-hospital system with hundreds of outpatient clinical settings … With falls, for example, we have an aging population. … As we transfer care from hospital-based to ambulatory to home-based, the people who end up in the hospital … population at risk for falls.

Competence and certification of registered nurses and safety of patients in intensive care units. | PSNet

psnet.ahrq.gov/issue/competence-and-certification-registered-nurses-and-safety-patients-intensive-care-units

May 01, 2006 - certified registered nurses had lower rates of certain patient safety outcomes, including incidence of falls … January 3, 2017 AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses … February 18, 2011 Patient whiteboards as a communication tool in the hospital setting … hospital ICU. … June 2, 2010 Worries and concerns experienced by nurse specialists during inter-hospital

Electrocardiogram Results: READ ME | PSNet

psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me

May 01, 2019 - The case raised concerns about the review of ECGs routinely performed in the hospital setting and often … It would have been appropriate for the hospital where this error occurred to instruct all nurses aides … What reasonable measures should hospitals take to prevent this type of error from occurring? … Hospitals and physicians should develop systems approaches to patient care that minimize the chance for … May 31, 2023 Patient Safety Innovations Preventing Falls

Strategies to Improve Organizational Health Literacy. | PSNet

psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy

August 30, 2023 - Errors in care and adverse events associated with health literacy include mistakes in diabetes management … for children ; 3 incorrect use of inhalers and aerosol medications; 4 falls; delays in receiving … generic (e.g., Health Literate Health Care Organization-10 6 or the Health Literacy Environment of Hospitals … high risk situation such as when patients are prescribed medications or are discharged from the hospital … August 12, 2020 View More See More About The Topic Hospitals Long-Term

Adverse Events, Near Misses, and Errors | PSNet

psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors

March 30, 2022 - Twenty-two months later, after a 14-kg (30 lb) weight loss, he was admitted to a hospital for evaluation … For example, consider a patient who is admitted to the hospital and placed in a shared room. … if care had been different; Adverse events due to negligence : those that occurred due to care that falls … Acute Hospital Care Units April 26, 2023 ISMP medication error report analysis … April 15, 2015 View More See More About The Topic Hospitals Health

Indiana Medical Error Reporting System. | PSNet

psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015

July 15, 2009 - mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) … among various hospital-based healthcare professionals and trainees in a simulated patient room. … to 20 hospitals in England during implementation of the 7-day services national health policy. … October 25, 2023 Maryland Hospital Patient Safety Program Annual Report. … September 28, 2023 Hospital Performance Report.

Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet

psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable

August 10, 2019 - The fall occurred as she attempted to sit down in the bathroom and missed the toilet, falling backwards … On the first hospital day, the patient continued to have difficulty with maximal inspiration because … These protocols and checklists should be implemented in any location in any hospital where an invasive … Vincent's Hospital, Melbourne Melbourne Medical School Faculty of Medicine, Dentistry and Health Sciences … Melbourne Parkville, Victoria, Australia Yoshiaki Uda, MBBS Department of Anesthesia Toronto General Hospital

Geriatric medication reconciliation in the home setting. | PSNet

psnet.ahrq.gov/issue/geriatric-medication-reconciliation-home-setting

September 01, 2021 - Newspaper/Magazine Article Geriatric medication reconciliation in the home setting … Citation Text: Geriatric medication reconciliation in the home setting. Taylor K. … 2018 Implementation of simulation training during the COVID-19 pandemic: a New York hospital … February 6, 2013 Patients taking their own medications while in the hospital. … Strategies to improve the patient safety outcome indicator: preventing or reducing falls

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey. | PSNet

psnet.ahrq.gov/issue/assessment-patients-ability-review-electronic-health-record-information-identify-potential

July 27, 2022 - providing online access to EHRs identified several barriers to understanding information contained in … January 12, 2022 Drug-related problems and polypharmacy in nursing home residents: a … care units and hospital emergency services. … May 1, 2015 Patient identification errors: the detective in the laboratory. … October 1, 2008 View More See More About The Topic Hospitals

Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error. | PSNet

psnet.ahrq.gov/issue/unscheduled-return-visits-emergency-department-icu-admission-trigger-tool-diagnostic-error

December 02, 2020 - if they were associated with deviations in care and to understand the common errors. … those, 14% (31 cases) had a deviation in care at the index visit. … care, 47.3% had a failure in the initial diagnostic pathway. … hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals … July 1, 2016 Hospitals overhaul ERs to reduce mistakes.

Impact of the primary care nurse manager on nurse intent to leave and staff perception of patient safety. | PSNet

psnet.ahrq.gov/issue/impact-primary-care-nurse-manager-nurse-intent-leave-and-staff-perception-patient-safety

November 01, 2023 - a multistate hospital network--13 academic medical centers, April-June 2020. … February 1, 2023 Missed nursing care in pediatrics. … hospital practice: factors associated with turnover, outcomes, and patient safety. … medical settings among Muslim women in the USA. … November 29, 2023 The complexities of communication at hospital discharge of older patients

Reducing risks in complex care transitions in rural areas: a grounded theory. | PSNet

psnet.ahrq.gov/issue/reducing-risks-complex-care-transitions-rural-areas-grounded-theory

June 23, 2021 - Reducing risks in complex care transitions in rural areas: a grounded theory. … Reducing risks in complex care transitions in rural areas: a grounded theory. … April 5, 2023 How do hospital inpatients conceptualise patient safety? … hospital in-patients: evaluation using Reason's accident causation theory. … December 23, 2020 View More See More About The Topic Hospitals Quality

Exploring approaches to patient safety: the case of spinal manipulation therapy. | PSNet

psnet.ahrq.gov/issue/exploring-approaches-patient-safety-case-spinal-manipulation-therapy

September 11, 2024 - preparedness of an alternative care hospital during COVID-19 pandemic. … survival after in-hospital cardiac arrests. … August 14, 2013 Diet order entry by registered dietitians results in a reduction in error … August 26, 2020 Fatigue and safety in paramedicine. … out-of-hospital care: an ethnographic view.

TIPS (Topics in Patient Safety). | PSNet

psnet.ahrq.gov/issue/tips-topics-patient-safety

May 24, 2017 - Government Resource TIPS (Topics in Patient Safety). … Citation Text: TIPS (Topics in Patient Safety). National Center for Patient Safety. … May 24, 2017 National Center for Patient Safety Falls Toolkit 2004. … Truman Memorial Veterans' Hospital in Columbia, Missouri. … Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

Proactive patient safety: focusing on what goes right in the perioperative environment. | PSNet

psnet.ahrq.gov/issue/proactive-patient-safety-focusing-what-goes-right-perioperative-environment

April 26, 2023 - Proactive patient safety: focusing on what goes right in the perioperative environment. … In this article, the authors describe safety attitudes of perioperative staff after participating in … April 12, 2023 Composite measures for profiling hospitals on bariatric surgery performance … December 11, 2024 Judgment errors in surgical care. … analysis of closed medico-legal cases and complaints in Canada.

Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care nurses. | PSNet

psnet.ahrq.gov/issue/moral-distress-compassion-fatigue-and-perceptions-about-medication-errors-certified-critical

November 09, 2015 - Study Moral distress, compassion fatigue, and perceptions about medication errors in … Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care … Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care … July 22, 2010 Implementing universal suicide risk screening in a pediatric hospital. … June 2, 2010 Worries and concerns experienced by nurse specialists during inter-hospital

The safety of Australian healthcare: 10 years after QAHCS. | PSNet

psnet.ahrq.gov/issue/safety-australian-healthcare-10-years-after-qahcs

January 12, 2022 - The authors reflect on the progress in patient safety in the 10 years since the Quality in Australian … March 6, 2019 Risk factors for clinically relevant deviations in patients' medication … lists reported by patients in personal health records: a prospective cohort study in a hospital setting … Hazards in delivery of surgical instruments. … August 10, 2016 Risky procedures by nurses in hospitals: problems and (contemplated)

Stand-alone artificial intelligence for breast cancer detection in mammography: comparison with 101 radiologists. | PSNet

psnet.ahrq.gov/issue/stand-alone-artificial-intelligence-breast-cancer-detection-mammography-comparison-101

November 15, 2023 - Classic Stand-alone artificial intelligence for breast cancer detection in … a multistate hospital network--13 academic medical centers, April-June 2020. … August 21, 2019 Fatigue in radiology: a fertile area for future research. … July 31, 2019 Error and Uncertainty in Diagnostic Radiology. … August 9, 2011 View More See More About The Topic Hospitals Physicians

U.S. Food and Drug Administration Precertification pilot program for digital health software: weighing the benefits and risks. | PSNet

psnet.ahrq.gov/issue/us-food-and-drug-administration-precertification-pilot-program-digital-health-software

September 25, 2008 - Innovation is a valuable process in health care. … September 25, 2008 Families as partners in hospital error and adverse event surveillance … International variations in the safety information accompanying top-selling prescription drugs. … November 16, 2022 Incidence and trends of sepsis in US hospitals using clinical vs claims … August 20, 2018 Changes in medical errors after implementation of a handoff program.

Applied use of safety event occurrence control charts of harm and non-harm events: a case study. | PSNet

psnet.ahrq.gov/issue/applied-use-safety-event-occurrence-control-charts-harm-and-non-harm-events-case-study

October 23, 2024 - process or workflow changes to indicate reliability of care in real time. … Clinicians' use of health information exchange technologies for medication reconciliation in … June 1, 2016 Adverse events in healthcare: learning from mistakes. … February 14, 2007 View More See More About The Topic Hospitals Health … Care Executives and Administrators Information Professionals Safety Scientists Hospital Medicine

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