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www.ahrq.gov/research/findings/studies/index.html?page=477
January 01, 2024 - with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hospitals … that elected not to participate in Hospital Compare. … Keywords: Hospitals, Outcomes, Public Reporting, Quality Improvement, Surgery
Ness GL , Sheehan … associations of HCTD and number of chronic diseases, and conditions that add to health status complexity (falls … Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. … of hospitalized patients can lead to increased lengths of stay, in-hospital complications, and preventable … Communication behaviours in a hospital setting: an observational study. … May 31, 2023
Patient Safety Innovations
Preventing Falls … Fumbled Handoff
March 1, 2004
View More
See More About The Topic
Hospitals
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hcup-us.ahrq.gov/reports/methods/FinalReportonObservationStatus_v2Final.pdf
January 01, 2010 - various trends in hospital utilization. … in any part of the hospital outside of inpatient admission to the
hospital. … The code for observation services falls under
a category called “760 Treatment or Observation Room” … all hospitals and hospitals with observation services in Figure 2. … quarter by hospital
in State O.
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www.ahrq.gov/research/findings/studies/index.html?page=55
January 01, 2024 - The study used data from 177 US hospitals in the Premier Healthcare Database and 12 Cleveland Clinic … Health System (CCHS) hospitals. … point-of-care ultrasound in hospital medicine: a national survey of VA hospitals. … Current use, training, and barriers in point-of-care ultrasound in hospital medicine: a national survey … of VA hospitals.
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/nm10.jsp
July 01, 2016 - slide 11
Levels of Influence in Hospitals
Graphic Diagram showing the Health Information Systems … early Fall 2012
8 hospital trainings complete; 35 hospitals still need training
Goal: Reduce … Feedback to hospitals:
Hospital Specific Progress Reports describing:
Patient demographics compared … the hospital data
slide 20
Focus Groups
Native American populations served in non-Indian Health … many missing, other or unknown race/ethnicity/tribal affiliation
Hospitals have to negotiate with
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - Workgroup through Education and Research (POWER) is an initiative of 39 delivering hospitals in Arkansas … Of the 39 delivering hospitals, all hospitals have >60% completion of the postpartum hemorrhage bundle … were facilitated to the closest, most appropriate hospital in 2011, 554 in 2013, and 451 in the 2018 … hospital administrators, family practitioners, and obstetricians at rural hospitals and private practices … April 17, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Examples include patients who may be on medications that could increase their risk of falls or bleeding … Malpractice risk in communication failures. Boston, MA. 2015. … In: Henriksen K BJ, Keyes MA, Grady ML, ed. … July 20, 2022
Human factors considerations in using personal protective equipment in … See More About The Topic
Culture of Safety
Communication between Providers
Hospitals
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/guide.html
March 01, 2017 - Leadership and staff perceptions of resident harms such as CAUTIs or falls, and staff harm such as a … Leaders, clinicians, frontline staff, and residents and families should be included in the process in … All staff in an LTC facility should also understand why practices are in place to improve the quality … of care in the LTC facility. … Toolkit for Reducing CAUTI in Hospitals .
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Pratt.pdf
March 01, 2004 - So they were quite receptive when SDCPS
approached San Diego hospitals in the summer of 2002 to join … Consortium initiatives, and avoiding competition between
hospitals in terms of patient safety records … to hospital.
2. … This was another opportunity for all of
the hospital pharmacies to benefit from the work done in each … For
example, if a patient dies in one hospital because of a medical device failure or an
unusual drug
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Pratt.pdf
March 01, 2004 - So they were quite receptive when SDCPS
approached San Diego hospitals in the summer of 2002 to join … Consortium initiatives, and avoiding competition between
hospitals in terms of patient safety records … to hospital.
2. … This was another opportunity for all of
the hospital pharmacies to benefit from the work done in each … For
example, if a patient dies in one hospital because of a medical device failure or an
unusual drug
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - psychiatric units were medication errors (17.2 per 100 discharges), adverse drug
events (4.1), and falls … Analysis of 12 years' worth of root cause analysis reports from all VA hospitals in the US identified … hospital with a free-standing psychiatric facility. … Behavioral health staff in free-standing psychiatric hospitals may have limited access to physicians … Inpatient suicide on mental health units in Veterans Affairs
(VA) hospitals: avoiding environmental
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effectivehealthcare.ahrq.gov/products/coronary-artery-stenting/research-protocol
August 29, 2011 - Such an evaluation clearly falls outside the scope of our review, which is to evaluate the impact of … They are as follows:
Short-term (≤30 days) outcomes:
In-hospital procedural outcomes
Process outcomes … the following settings:
Tertiary care centers or community hospitals
In-hospital or stand-alone catheterization … patients undergoing PCI, and improve short-term (in hospital or discharge to 30 days), intermediate … They will be further categorized to specific epochs: in hospital, discharge to 30 days, >30 days to 1
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/coronary-artery-stenting_research-protocol.pdf
August 19, 2011 - Such an evaluation clearly falls outside the scope of our review, which is to evaluate the
impact of … They are as follows:
• Short-term (≤30 days) outcomes:
o In-hospital procedural outcomes
… the following settings:
o Tertiary care centers or community hospitals
o In-hospital or stand-alone … patients
undergoing PCI, and improve short-term (in hospital or discharge to 30 days), intermediate … They will be further categorized to specific epochs: in hospital, discharge to
30 days, >30 days to
-
effectivehealthcare-admin.ahrq.gov/sites/default/files/pdf/coronary-artery-stenting_research-protocol.pdf
August 19, 2011 - Such an evaluation clearly falls outside the scope of our review, which is to evaluate the
impact of … They are as follows:
• Short-term (≤30 days) outcomes:
o In-hospital procedural outcomes
… the following settings:
o Tertiary care centers or community hospitals
o In-hospital or stand-alone … patients
undergoing PCI, and improve short-term (in hospital or discharge to 30 days), intermediate … They will be further categorized to specific epochs: in hospital, discharge to
30 days, >30 days to
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - VA has installed bar-coded medication administration (BCMA) in nearly all hospitals, and most clinicians … Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-274. … RW: In a practical sense, let's say I'm in a VA hospital in Des Moines and I'm newly hired to run the … U.S. hospitals. … June 21, 2016
Association between patient outcomes and accreditation in US hospitals:
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
May 25, 2023 - Hospitals in
Massachusetts in CY2018
► 24% admissions with adverse event
► 7% admissions with preventable … Health Workforce
• The Joint Commission – National Patient
Safety Goals
• CMS initiatives (i.e., Hospital … Assessment
Goal - complete the assessment with 12 ministry markets by March 2023
Who: Market and Hospital … Pugh 2FQ’23 • Community grant recipients selected, announced;
$50K/hospital to distribute through grants … such thing as
surge … our new normal
*Healthcare Acquired Infections, Early Elective
Deliveries, Falls
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
May 25, 2023 - Hospitals in
Massachusetts in CY2018
► 24% admissions with adverse event
► 7% admissions with preventable … Health Workforce
• The Joint Commission – National Patient
Safety Goals
• CMS initiatives (i.e., Hospital … Assessment
Goal - complete the assessment with 12 ministry markets by March 2023
Who: Market and Hospital … Pugh 2FQ’23 • Community grant recipients selected, announced;
$50K/hospital to distribute through grants … such thing as
surge … our new normal
*Healthcare Acquired Infections, Early Elective
Deliveries, Falls
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - due to a worsening wound from an amputation of the first metatarsal of right great toe at a different hospital … Upon hospital admission, she was stabilized medically and sent to surgery for a trans-metatarsal foot … While this topic falls outside of the scope of this commentary, it remains critical to treat the whole … In: StatPearls . … October 18, 2023
Physician EHR adoption and potentially preventable hospital admissions
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www.ahrq.gov/research/findings/studies/index.html?page=43
January 01, 2024 - rise in in-hospital infection probability and a 0.183 increase in the likelihood of 90-day infection … Comparable findings were observed in models assessing the number of in-hospital and 90-day infections … lung injury, medication and diagnostic errors, oversedation, oxygen device removal, and falls. … A cohort of 600 patients were included, with in-hospital mortality of 40.3%. … Intubations lasting longer than 21 days had a lower in-hospital mortality of 25.7%.
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - In contrast, a weak action step would be “update a policy on test result
communication.” … The toolkit’s flexibility also means it can be adapted for diverse healthcare settings beyond hospitals … to examine patterns across multiple events within a category (such as medication
errors or patient falls … RCA Methodology
In addition to RCA2, there have been other recent innovations in RCA methodology. … The challenges of undertaking root cause analysis in health care: a
qualitative study.