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Eliminating Serious, Preventable, and Costly Medical Errors - Never Events. | PSNet

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May 26, 2021 - March 10, 2021 Hospital-Acquired Condition Reduction Program (HACRP). … November 23, 2015 Medicare and Medicaid Programs and the Children’s Health Insurance … Medicaid program; payment adjustment for provider-preventable conditions including health … July 2, 2009 View More See More About The Topic Health Care Providers … Health Care Executives and Administrators Medicine Pharmacy Identification Errors

WebM&M: Case Studies | PSNet

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March 25, 2025 - Structured Hand-offs (64) Provider-Patient Communication (95) Health … Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation … Despite conservative management at home, his condition worsened over several weeks before being readmitted … Despite initial treatment, her condition did not improve as expected. … She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income Seniors and other High-Risk Populations | PSNet

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July 23, 2024 - The protocols for each condition spell out specific interventions to be considered for implementation … For each condition present, the corresponding protocol recommendations, along with additional recommendations … care system (Wishard Health Services now called Eskenazi Health) serving many medically indigent patients … This analysis showed that program participants were more likely than usual-care patients to have their condition … Improved health status and self-rated health: Compared with the control group, participants exhibited

Getting the Diagnosis Both Right and Wrong | PSNet

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May 29, 2024 - First, it is important to consider that clinicians' prompt recognition of one condition—tumor lysis syndrome—likely … the very same case, clinicians' pattern recognition failed to identify a much more common clinical condition … Since existing programs focused on teamwork are already well-rooted in many health care systems and health … Improving Diagnosis in Health Care. … Do work condition interventions affect quality and errors in primary care?

Adult Hospital Stays with Infections Due to Medical Care, 2007. | PSNet

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April 27, 2011 - This report presents data on health care–associated infections (HAI) that reveals a reduction of … Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition

Spinal Epidural Abscess | PSNet

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November 13, 2019 - challenges is that the initial presentation can be similar to an extremely common everyday medical condition … Thoracic spinal epidural abscess is a rare but serious condition that may only present with low back … Improving Diagnosis in Health Care. … Department of Health and Human Services. … Department of Health and Human Services.

Health Plan Patient Safety Initiatives | PSNet

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July 10, 2024 - Plan’s Role In addition to health plans’ focus on quality, health plans can play an important role in … By regularly monitoring the safety of health care facilities in the health plan network, health plans … Health Insurance Exchanges. … Amy Helwig: Health plans, like all other stakeholders in health care, are invested in the best care … care, for example emergency or urgent or next day appointments that are appropriate depending on their condition

Pitfalls in Diagnosing Necrotizing Fasciitis | PSNet

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March 24, 2021 - History and Epidemiology Hippocrates first alluded to a clinical condition of "necrotizing erysipilas … 15% to 45%.( 15 ) Pathophysiology of Necrotizing Fasciitis Necrotizing fasciitis is a peculiar condition … consistent feature noted at the time of presentation.( 30,31 ) We found a regular review of the patient's condition … Department of Health and Human Services. … Department of Health and Human Services.

Conducting safety research safely: a policy-based approach for conducting research with peer review protected material. | PSNet

psnet.ahrq.gov/issue/conducting-safety-research-safely-policy-based-approach-conducting-research-peer-review

June 15, 2022 - December 9, 2020 Rising drug allergy alert overrides in electronic health records: an … February 14, 2017 The safety of outpatient health care: review of electronic health records … May 15, 2024 The safety of inpatient health care. … care use, medication adherence, and chronic condition control. … April 21, 2021 How administrative burdens can harm health.

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. | PSNet

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June 27, 2018 - Surgical site infections are a common hospital-acquired condition. … December 14, 2010 View More See More About The Topic Operating Room Health

Implementation of patient safety structures and processes in the patient-centered medical home. | PSNet

psnet.ahrq.gov/issue/implementation-patient-safety-structures-and-processes-patient-centered-medical-home

September 28, 2022 - medical home (PCMH) model is to reorganize primary care to provide team-based, coordinated, accessible health … Quality April 26, 2023 Association between opioid tapering and subsequent health … care use, medication adherence, and chronic condition control. … December 2, 2020 Patient safety in primary care: conceptual meanings to the health care … factors associated with an increased risk of being a reported case of preventable harm in first-line health

Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? | PSNet

psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it

March 15, 2016 - composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health … Health Serv Res. 2016;51(6):2140-2157. doi:10.1111/1475-6773.12596. … Health Serv Res . 2016; 51 (6) :2140-2157 . View more articles from the same authors. … 15% of hospitals in the study would face changes in financial penalties under the Hospital-Acquired Condition … Health Serv Res. 2016;51(6):2140-2157. doi:10.1111/1475-6773.12596.

Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet

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December 14, 2022 - Besides LAM, other rare causes of cystic lung disease include Birt-Hogg-Dube, a genetic condition affecting … not consider the potential of this diagnosis and thus definitive treatment for the patient’s serious condition … recommended measures to increase awareness of LAM and trigger specialized evaluation and treatment of this condition … Department of Health and Human Services. … Department of Health and Human Services.

Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. | PSNet

psnet.ahrq.gov/issue/centers-medicare-and-medicaid-services-hospital-acquired-conditions-policy-central-line

July 03, 2016 - The Centers for Medicare and Medicaid Services (CMS) nonpayment policy for health care–associated … The authors conclude that the nonpayment policy for health care–associated infections did not have its … RIS Download Citation Related Resources From the Same Author(s) Health … October 13, 2018 Hospital-Acquired Condition Reduction Program (HACRP). … April 5, 2013 Injection practices among clinicians in United States health care settings

Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit. | PSNet

psnet.ahrq.gov/issue/using-crew-resource-management-and-read-and-do-checklist-reduce-failure-rescue-events-step

November 04, 2020 - Related Resources From the Same Author(s) A high-reliability organization framework for health … November 4, 2020 Nursing crew resource management: a follow-up report from the Veterans Health … A follow-up study from US Veterans Health Administration medical centers. … November 21, 2016 Implementation of Condition Help: family teaching and evaluation of … View More See More About The Topic Hospitals Physicians Nurses Health

Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration | PSNet

psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital

October 30, 2024 - detection allowed clinicians to devise and implement a care plan to prevent deterioration of the patient’s condition … Once the algorithm was developed and integrated into the electronic health record (EHR), a team of virtual … by the clinical care team, such as transfer to an ICU, to prevent further worsening of the patient’s condition … Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health … 7, 2022 View More See More About The Topic General Hospitals Health

Assessment of potentially inappropriate prescribing of opioid analgesics requiring prior opioid tolerance. | PSNet

psnet.ahrq.gov/issue/assessment-potentially-inappropriate-prescribing-opioid-analgesics-requiring-prior-opioid

October 19, 2022 - identified from prescription drug claims had evidence of opioid tolerance in structured electronic health … November 16, 2022 Seroprevalence of SARS-CoV-2 among frontline health care personnel … management best practices from multispecialty organizations during the COVID-19 pandemic and public health … More Related Resources Association between opioid tapering and subsequent health … care use, medication adherence, and chronic condition control.

Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative. | PSNet

psnet.ahrq.gov/issue/eliminating-cauti-interim-data-report-national-patient-safety-imperative

August 01, 2012 - Care Needs Through Health IT Grant Initiative. … October 5, 2015 AHRQ Health Information Technology Research: 2018 Year in Review. … Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition … September 15, 2010 View More See More About The Topic Hospitals Health … Care Providers Health Care Executives and Administrators General Internal Medicine Hospital

A meta-review of methods of measuring and monitoring safety in primary care. | PSNet

psnet.ahrq.gov/issue/meta-review-methods-measuring-and-monitoring-safety-primary-care

November 03, 2021 - Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117. … Int J Qual Health Care . 2021; 33 (3) :mzab117 . … Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117. … July 27, 2022 A systematic review of patient-report safety climate measures in health … care use, medication adherence, and chronic condition control.

In Conversation With… Harlan Krumholz, MD, SM | PSNet

psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm

April 01, 2018 - Our study showed that they cannot recount the basic facts of their condition or what happened to them … that we're not very good at everything from discharge summaries to having any sense of our patient's condition … People come in the hospital with a condition. … treatment outcomes.( 7 ) Providers must communicate key information required for patients to manage their condition … Post-hospital syndrome–an acquired, transient condition of generalized risk.

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