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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - You can have an 80 year old in amazing physical condition [that would not be considered frail], or you … younger patients. 1 As individuals age, the likelihood increases that they have a chronic medical condition … Older adults are at an increased risk of experiencing a hospital acquired condition (HAC) or safety event … Edmonton Frail Scale. 6 Consider a horizontal approach The typical approach for preventing HACs on a condition … by condition basis has been very successful, with continuous and steady declines in the rate of HACs
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - patient's history of bleeding and prior transfusions, slow response to the patient's deteriorating condition … that hysterotomy should avoid the placenta site if possible; in the setting of anterior previa, this condition … Stanford, CA: California Department of Public Health, Maternal, Child and Adolescent Health Division, … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - Rarely, as in this case, vertigo represents the presenting symptom of a life-threatening, treatable condition … What led to this patient's demise despite having an easily diagnosed, treatable condition? … Since a patient's condition may change over the course of hours, this patient should have been examined … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change
November 16, 2022 - Missed diagnosis of a dangerous condition in utero, treatment errors , lack of response to concerns … Resources
Interview
In Conversation With...Amy Helwig about Health … Initiatives
July 10, 2024
Perspectives on Safety
Health … May 31, 2023
Examining the Status of VA’s Electronic Health Record Modernization Program
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psnet.ahrq.gov/issue/perspectives-patient-and-family-engagement-reduction-harm-forgotten-voice
December 01, 2011 - Exploring the concept of medication discrepancy within the context of patient safety to improve population health … November 30, 2016
Condition concern: an innovative response system for enhancing hospitalized … November 23, 2016
Implementation of Condition Help: family teaching and evaluation of
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psnet.ahrq.gov/issue/what-are-unintended-patient-safety-consequences-healthcare-technologies-qualitative-study
February 26, 2020 - , five themes emerge: inequity of access, increased end-user burden, loss of the human element of health … the potential "gaming" of technology wherein a patient enters falsified data to suggest a worsening condition … September 27, 2023
Impact of providing patients access to electronic health records on … July 10, 2024
Implementation of a health information technology safety classification … system in the Veterans Health Administration's Informatics Patient Safety Office.
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Over the ensuing days, the patient’s condition deteriorated with worsening respiratory failure, progressive … However, the rarity of this condition, especially if it involves a subacute presentation—as likely occurred … Health Aff (Millwood). 2018;37:1736-1743.
Kassirer JP. … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - only briefed on the initial respiratory distress and did not have a complete picture of the child's condition … Yet, if that is all that happened, the next child in this same condition in this same institution will … The implications of the resident and nursing staff not recognizing the seriousness of the child's condition … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/issue/exploratory-analysis-association-between-healthcare-associated-infections-hospital-financial
June 12, 2024 - with increased hospital costs, underscoring the importance of infection control policies to patient health … and hospital financial health . … September 26, 2018
Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition … June 28, 2017
Health care-associated infections: a meta-analysis of costs and financial … impact on the US health care system.
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - younger patients. 1 As individuals age, the likelihood increases that they have a chronic medical condition … Older adults are at an increased risk of experiencing a hospital acquired condition (HAC) or safety event … Edmonton Frail Scale. 6 Consider a horizontal approach The typical approach for preventing HACs on a condition … by condition basis has been very successful, with continuous and steady declines in the rate of HACs … You can have an 80 year old in amazing physical condition [that would not be considered frail], or you
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psnet.ahrq.gov/issue/building-program-expanded-peer-support-entire-health-care-team-no-one-left-behind
May 26, 2021 - Study
Building a program of expanded peer support for the entire health care team … Building a program of expanded peer support for the entire health care team: no one left behind. … The most common event supported was inability to stop the progress of a medical condition, including … Building a program of expanded peer support for the entire health care team: no one left behind. … October 19, 2022
The perception of the patient safety climate by health professionals
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psnet.ahrq.gov/issue/simulation-debriefing-enhanced-needs-assessment-address-quality-markers-health-care
June 22, 2022 - Study
Simulation-debriefing enhanced needs assessment to address quality markers in health … Simulation-debriefing enhanced needs assessment to address quality markers in health care: an innovation … Assessment (SDENA) to identify behavioral barriers and enablers for implementing healthcare-acquired condition … Simulation-debriefing enhanced needs assessment to address quality markers in health care: an innovation … July 2, 2019
Personal formularies of primary care physicians across 4 health care systems
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psnet.ahrq.gov/issue/patients-toolkit-diagnosis
November 08, 2017 - Patient engagement has been promoted as a strategy to enhance safety in health care. … April 5, 2023
A call to action: next steps to advance diagnosis education in the health … Improving Diagnostic Safety and Quality
April 26, 2023
Condition … March 1, 2004
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See More About The Topic
Hospitals
Health
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psnet.ahrq.gov/issue/sepsis-quality-safety-net-hospitals-analysis-medicares-sep-1-performance-measure
May 05, 2021 - the CMS SEP-1 quality measure and this association was most evident in hospitals not affiliated with health … The authors concluded existing sepsis policies may harm safety-net hospitals and widen health disparities … Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition … May 1, 2013
Making Health Care Safer: A Critical Analysis of Patient Safety Practices … December 14, 2009
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Hospitals
Health
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psnet.ahrq.gov/issue/role-bias-clinical-decision-making-people-serious-mental-illness-and-medical-co-morbidities
November 10, 2021 - J Behav Health Serv Res. 2023;50(2):236-262. doi:10.1007/s11414-022-09829-w. … J Behav Health Serv Res . 2023; 50 (2) :236-262 . … diagnostic overshadowing of a patient with substance use disorder led to undertreatment of a cardiovascular condition … J Behav Health Serv Res. 2023;50(2):236-262. doi:10.1007/s11414-022-09829-w. … information technology in the safe integration of behavioral health and primary care to improve patient
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psnet.ahrq.gov/continuing-education
February 26, 2025 - CEU) and Maintenance of Certification (MOC) credit through the University of California, Davis (UCD) Health … the American Board of Internal Medicine by the Office of Continuing Medical Education (OCME) at UCD, 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 … She heard the surgeon verbally acknowledge her condition and offer reassurance that the operation was
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psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health … at the interface between humans and a complex system) and latent
errors (the hidden problems within health … psnet.ahrq.gov/glossary/active-error-or-active-failure
https://psnet.ahrq.gov/glossary/latent-error-or-latent-condition … https://psnet.ahrq.gov/glossary/latent-error-or-latent-condition
https://psnet.ahrq.gov/primer/detection-safety-hazards
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psnet.ahrq.gov/issue/association-dose-tapering-overdose-or-mental-health-crisis-among-patients-prescribed-long
July 13, 2022 - Study
Association of dose tapering with overdose or mental health crisis among patients … Association of dose tapering with overdose or mental health crisis among patients prescribed long-term … Association of dose tapering with overdose or mental health crisis among patients prescribed long-term … adherence, and chronic condition control. … June 22, 2022
Factors associated with mental health outcomes among health care workers
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psnet.ahrq.gov/issue/strengths-and-weaknesses-diagnostic-process-endometriosis-patients-perspective-focus-group
March 06, 2019 - Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis … factors for clinically relevant deviations in patients' medication lists reported by patients in personal health … May 4, 2022
Patient-safety incidents during COVID-19 health crisis in France: An exploratory … View More
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Ambulatory Clinic or Office
Health
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psnet.ahrq.gov/issue/diseases-medical-progress
June 27, 2018 - Many of these continue to treat one illness but place patients at risk for developing a secondary condition … Related Resources From the Same Author(s)
Educating for the 21st-century health … July 19, 2023
Disclosing large scale adverse events in the US Veterans Health Administration … June 14, 2017
Context-sensitive decision support (infobuttons) in electronic health records