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psnet.ahrq.gov/issue/hospital-preparedness-covid-19-surge-assessment-tool
September 16, 2020 - Boston, MA: Institute for Healthcare Improvement; 2020. … March 27, 2019
No Place Like Home: Advancing the Safety of Care in the Home. … June 2, 2021
"At home, with care": lessons from New York City home-based primary care … workers
July 8, 2020
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Hospitals
Health … Care Executives and Administrators
Quality and Safety Professionals
Public Health
Infectious
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - The error of resuscitating a patient because health care providers were unaware of his code status reflects … It is this delayed communication that can lead to higher health care costs and higher utilization of … Rather, health care providers need to be trained in a goal-based approach to advance care planning in … Second, based on understanding where the patient is in his or her disease trajectory, the health care … Health Care Transitions and Incident Feeding Tube Insertion Among Persons with Advanced Cognitive Impairment
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - systems should make efforts to understand and re-
engage LTFU patients, as LTFU can lead to permanent … completed as the patient indicated his
clear views regarding advance directives and durable power for health … care. … The health care cost of palliative care for cancer patients: a systematic review. … Points
Take-Home Points (1)
Take-Home Points (2)
References
References
References
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Process Variation The health care professionals in this case failed to accurately review and document … Allowing for at least two health care professionals in verifying the identity, dosage, and instructions … health care professional and made available across all patient encounters. … Care Providers
Risk Managers
Quality and Safety Professionals
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psnet.ahrq.gov/issue/assisting-beginners-root-cause-analysis-operations-analysis-and-recommendations-regarding
June 08, 2022 - analysis using the prevention and recovery information system for monitoring and analysis method in healthcare … May 25, 2022
Prioritising recommendations following analyses of adverse events in healthcare … Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare … system: results of the DEMEANOR pragmatic, cluster, cross-over trial. … October 28, 2020
Expanding frontiers of risk management: care safety in nursing home
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psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
February 15, 2017 - Cambridge, MA: Institute for Healthcare Improvement; November 2015. … Cambridge, MA: Institute for Healthcare Improvement; November 2015. … Cambridge, MA: Institute for Healthcare Improvement; November 2015. … August 9, 2017
Optimizing a Business Case for Safe Health Care: An Integrated Approach … Care Executives and Administrators
Geriatrics
Epidemiology of Errors and Adverse Events
Audit
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psnet.ahrq.gov/issue/patient-safety-and-ethical-implications-healthcare-sick-leave-policies-pandemic-era
September 16, 2020 - care. … July 6, 2022
Communication with patients and families regarding health care-associated … care clinician behaviors. … October 28, 2020
Expanding frontiers of risk management: care safety in nursing home … May 6, 2020
Understanding and addressing sources of anxiety among health care professionals
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psnet.ahrq.gov/issue/nurse-physician-communication-long-term-care-setting-perceived-barriers-and-impact-patient
February 23, 2011 - March 17, 2021
The association of nursing home characteristics and quality with adverse … Organization (HRO) Principles and Patient Safety
February 26, 2025
National Healthcare … November 23, 2011
Nursing Home Survey on Patient Safety Culture: 2011 User Comparative … June 2, 2010
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Long-Term Care
Health … Care Providers
Health Care Executives and Administrators
Organizational Behaviorists
Geriatrics
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psnet.ahrq.gov/issue/sustaining-improvement
January 09, 2019 - August 9, 2017
Improving the Reliability of Health Care. … July 27, 2018
Bracing for the storm: one health care system's planning for the COVID- … November 11, 2020
Health care quality and safety in a correctional system: creating goals … April 17, 2018
Transforming Health Care: A Compendium of Reports From the National Patient … June 23, 2010
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Hospitals
Health Care
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psnet.ahrq.gov/issue/multidose-drug-dispensing-and-discrepancies-between-medication-records
November 06, 2013 - Qual Saf Health Care. 2010;19(5):e42. doi:10.1136/qshc.2009.038745. … Qual Saf Health Care . 2010; 19 (5) :e42 .
View more articles from the same authors. … Qual Saf Health Care. 2010;19(5):e42. doi:10.1136/qshc.2009.038745. … Electronic communication of medication information between nurses in home health care and general practitioners … August 22, 2015
Patients' negative experiences with health care settings brought to light
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psnet.ahrq.gov/issue/scoping-review-methodological-approaches-used-retrospective-chart-reviews-validate-adverse
April 29, 2020 - Int J Qual Health Care. 2024;36(2):mzae037. doi:10.1093/intqhc/mzae037. … Int J Qual Health Care . 2024; 36 (2) :mzae037 . … Int J Qual Health Care. 2024;36(2):mzae037. doi:10.1093/intqhc/mzae037. … system. … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - care system in this way. … Ultimately, we need to better understand why our health care system has evolved to be so complex that … Clinicians and health care systems should address this problem systematically, just as they do with other … Physicians and other health care professionals can help patients navigate the health care system and … Like other patient safety issues, clinicians and health care systems should address this problem systematically
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - The 2008 Joint Commission Patient Safety Goal 2E requires all health care providers to "implement a standardized … Many health care systems require EMS providers to radio the receiving ED prior to arrival. … The Joint Commission Accreditation Program: Ambulatory Health Care National Patient Safety Goals. … Information transfer from prehospital to ED health care providers. … Care Providers
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psnet.ahrq.gov/issue/development-instrument-measure-seniors-patient-safety-health-beliefs-seniors-empowerment-and
February 15, 2011 - January 10, 2011
Patient safety incidents in home hospice care: the experiences of hospice … April 24, 2018
Enabling a learning healthcare system with automated computer protocols … A national implementation project to prevent catheter-associated urinary tract infection in nursing home … June 22, 2011
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See More About The Topic
Long-Term Care
Health … Care Providers
Educators
Geriatrics
Quality Improvement Strategies
View More
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psnet.ahrq.gov/issue/effect-medication-reconciliation-elderly-patients-hospital-discharge
February 04, 2009 - April 6, 2022
Healthcare workers' experiences of patient safety in the intensive care … July 12, 2023
The safe day call: reducing silos in health care through frontline risk … August 13, 2014
Electronic medication reconciliation tools aimed at healthcare professionals … and in a nursing home. … Care
Health Care Providers
Health Care Executives and Administrators
View More
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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - support systems, when implemented in isolation and exclusive of efforts to
improve communication between health … care providers, may have only limited benefits. … CMS Nursing Home Compendium 2010 Edition. … Improving medication safety in the nursing home setting: the case
of warfarin. … The safety of warfarin therapy in the nursing home setting. Am J
Med. 2007;120:539-544.
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psnet.ahrq.gov/issue/assessment-national-patient-safety-initiative-context-and-baseline-evaluation-report-1
May 21, 2014 - The authors report on the history of Agency for Healthcare Research and Quality's (AHRQ) involvement … Health Care System. … Care System. … Care Settings. … October 2, 2013
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Health Care Executives
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psnet.ahrq.gov/issue/deprescribing-medicines-older-people-living-multimorbidity-and-polypharmacy-tailor-evidence
April 03, 2005 - and in a nursing home. … July 7, 2021
Enabling a learning healthcare system with automated computer protocols … polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare … Latch
September 1, 2008
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Health … Care Providers
Geriatrics
Pharmacy
Ordering/Prescribing Errors
Epidemiology of Errors and
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Care . … Her interdisciplinary scholarship aims to improve healthcare delivery and relies on close partnerships … She currently serves as the Vice President of Healthcare Delivery Research at MedStar Health Research … delivery. … As an engineer at a non-profit healthcare system, he directed human factors and patient safety science
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psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2010-user-comparative-database-report
November 30, 2016 - Rockville, MD: Agency for Healthcare Research and Quality; March 2010. … Rockville, MD: Agency for Healthcare Research and Quality; March 2010. … Health Care System. … September 15, 2010
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Hospitals
Health … Care Executives and Administrators
General Internal Medicine
Hospital Medicine
Benchmarking