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psnet.ahrq.gov/issue/ahrq-announces-interest-health-services-research-reduce-emergency-department-boarding-and
November 12, 2008 - Emergency Medicine
Pediatric Emergency Medicine
Emergency Nursing
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/issue/safe-use-health-information-technology
December 23, 2016 - December 23, 2016
Inadequate hand-off communication.
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psnet.ahrq.gov/issue/association-between-electronic-health-record-implementations-and-hospital-acquired-conditions
September 01, 2016 - Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand
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psnet.ahrq.gov/issue/health-care-worker-fatigue-and-patient-safety
December 23, 2016 - December 23, 2016
Inadequate hand-off communication.
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psnet.ahrq.gov/issue/addressing-safety-concerns-about-u-500-insulin-hospital-setting
March 15, 2017 - October 3, 2012
Impact of a hospital-wide hand hygiene initiative on healthcare-associated
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psnet.ahrq.gov/issue/optimizing-patient-handoff-between-ems-and-emergency-department
April 24, 2018 - July 2, 2014
Parent willingness to remind health care workers to perform hand hygiene
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psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
November 18, 2015 - April 17, 2013
Hand hygiene deficiency citations in nursing homes.
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psnet.ahrq.gov/issue/checking-lists-systematic-review-electronic-checklist-use-health-care
August 08, 2018 - Hospitals
Health Care Providers
Information Professionals
Medicine
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/issue/year-end-resident-clinic-handoffs-narrative-review-and-recommendations-improvement
March 28, 2018 - Topic
Hospitals
Facility and Group Administrators
Medicine
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/issue/handoffs-and-communication-underappreciated-roles-situational-awareness-and-inattentional
February 01, 2003 - and Safety Professionals
Organizational Behaviorists
Educators
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/issue/effectiveness-interventions-improve-patient-handover-surgery-systematic-review
June 25, 2018 - Operating Room
Health Care Executives and Administrators
Surgery
Discontinuities, Gaps, and Hand-Off
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psnet.ahrq.gov/issue/towards-safer-better-healthcare-harnessing-natural-properties-complex-sociotechnical-systems
April 08, 2011 - Disentangling quality and safety indicator data: a longitudinal, comparative study of hand
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psnet.ahrq.gov/issue/social-capital-and-knowledge-sharing-effects-patient-safety
September 15, 2011 - January 12, 2011
Relationship between systems-level factors and hand hygiene adherence
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psnet.ahrq.gov/issue/adherence-simple-and-effective-measures-reduces-incidence-ventilator-associated-pneumonia
November 16, 2011 - June 8, 2016
Quantification of the Hawthorne effect in hand hygiene compliance monitoring
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4o_combo_pdi01-lacerationpuncture-bestpractices.pdf
May 31, 2016 - • Adopt a hands-free technique of passing suture needles and sharps between perioperative
team members
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4a_pdi01-lacerationpuncture-bestpractices.pdf
May 31, 2016 - • Adopt a hands-free technique of passing suture needles and sharps between perioperative
team members
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - (clinical) knowledge of the person involved: did he or she have sufficient training for the task at hand … simultaneous belief in individual strength and brittleness is pervasive in health care: Safety lies in the hands … through which care ultimately flows to the patient, not in the system that surrounds those hands.
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - the patient is, whether in DC or in the middle of the ocean, we need to extend our eyes, ears, and hands … KH : How do you continue to provide high-quality care when it’s now more hands-off? … However, there’ll be only one person that has their hands on the patient but everyone else will be observing … The hands-on person becomes the telepresenter as well as the treating clinician. … We have to get good at observing some of the other cues from the hands-on exam.
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hcup-us.ahrq.gov/db/state/siddist/HCUP-US2013NMSID.pdf
January 01, 2013 - As part of the on-going HCUP quality management program, we have identified an issue with
the 2013 New Mexico HCUP Central Distributor State Inpatient Databases (SID). The majority
of the records in this SID included total charge amounts that were double what they should be.
In addition there were a handful of sma…
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - activities that patients perceived to be confrontational, such as reminding providers to wash their hands … reducing adverse events than the more active behaviors, such as checking medications, asking about hand … of the health care team and encouraged to check their medications, ask providers to disinfect their hands … of a more delicate word, their clinicians—for example if they noticed that they didn't clean their hands … But I don't think all the responsibility for challenging people about hand-washing or other safety concerns