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  1. psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
    July 23, 2024 - It also included discharge resources (including a self-administered safety plan) and post-ED telephone … Data were collected from 2014 to 2018 and analyzed from April 2022 to December 2022. 3 The trial included … The measure included 1) an ED visit or hospitalization due to suicidal ideation/behavior or 2) death … The plans included interventions that patients could do on their own and ideas for interventions they … The innovators found the minimum investment to maintain results included quarterly meetings with the
  2. psnet.ahrq.gov/issue/analysis-prescribers-notes-electronic-prescriptions-ambulatory-practice
    July 23, 2018 - this large cross-sectional study, researchers analyzed more than 26,000 electronic prescriptions that included … Nearly 1 in 5 of these notes included conflicting administration instructions from the designated structured … The authors outline recommended solutions based on the information most commonly included in prescription
  3. psnet.ahrq.gov/issue/barriers-and-facilitators-healthcare-workers-adherence-infection-prevention-and-control-ipc
    March 02, 2011 - The authors included 20 studies in their analysis; these studies explored the views and experiences of … Identified barriers included local guidelines that were lengthy, ambiguous or not reflective of national … Facilitators to guideline adherence included clear communication and training about the infection and
  4. psnet.ahrq.gov/issue/safety-inpatient-health-care
    May 15, 2024 - This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly … Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity
  5. psnet.ahrq.gov/issue/abusive-supervision-and-its-relationship-nursing-workforce-and-patient-safety-outcomes
    October 25, 2023 - Among 21 included studies, common outcomes included turnover intention, job satisfaction , workplace
  6. psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
    June 19, 2024 - The VTE Collaborative’s efforts to improve the appropriate use of medication for VTE prophylaxis have included … Participants in the Collaborative have included physicians (e.g., surgeons, hematologists), quality and … Feedback included individual reports in which residents could see how they ranked in their prescribing … It was implemented in both an academic hospital and a community hospital and included targeting of blood … The other module provided interactive, dynamic, scenario-based education that included feedback and an
  7. psnet.ahrq.gov/issue/hospital-staff-reports-coworker-positive-and-unprofessional-behaviours-across-eight-hospitals
    May 01, 2024 - The most commonly reported positive behaviors included non-technical skills, values-driven behavior, … Frequently reported unprofessional behaviors included being rude, humiliating or ridiculing others, and
  8. psnet.ahrq.gov/issue/free-text-computerized-provider-order-entry-orders-used-workaround-communicating-medication
    July 29, 2020 - This study analyzed CPOE orders that included medication information in the free text field. … Despite using the same CPOE software, there were wide variations between the six included hospitals in
  9. psnet.ahrq.gov/issue/clinicians-insights-emergency-department-boarding-explanatory-mixed-methods-study-evaluating
    October 23, 2019 - Possible solutions included improved standardization of care, proactive planning, and culture change … initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included
  10. psnet.ahrq.gov/issue/differential-diagnosis-checklists-reduce-diagnostic-error-differentially-randomised
    September 23, 2020 - found that the checklist improved diagnostic accuracy compared to a prompt, but only if the checklist included … the correct diagnosis; if the correct diagnosis was not included on the checklist, diagnostic accuracy
  11. psnet.ahrq.gov/issue/patient-and-family-engagement-catheter-associated-urinary-tract-infection-cauti-prevention
    February 07, 2022 - This systematic review focused on CAUTI prevention interventions that included patient and family engagement … All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes
  12. psnet.ahrq.gov/issue/national-quality-program-achieves-improvements-safety-culture-and-reduction-preventable-harms
    November 02, 2022 - The program included an assessment of the quality at each site followed by an individual improvement … Each site embarked on a multimodal intervention that included leadership engagement, team training
  13. psnet.ahrq.gov/issue/adverse-events-long-term-care-residents-transitioning-hospital-back-nursing-home
    April 28, 2021 - adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included … Common adverse events included falls , pressure ulcers, health care–associated infections , and adverse
  14. psnet.ahrq.gov/issue/barriers-and-facilitators-patient-engagement-patient-safety-patients-and-healthcare
    June 09, 2021 - Barriers included both patient and provider unwillingness; facilitators included encouraging and sharing
  15. psnet.ahrq.gov/issue/there-evidence-better-health-care-cancer-patients-after-second-opinion-systematic-review
    May 03, 2023 - Researchers included studies that demonstrated varying estimates of second opinion rates, which could … The authors note the lack of relevant patient outcomes or standardized quality metrics across all included
  16. psnet.ahrq.gov/issue/medication-related-interventions-improve-medication-safety-and-patient-outcomes-transition
    October 27, 2021 - Seventeen studies were included with five identified intervention components. … Recommendations for improving transfers are included.
  17. psnet.ahrq.gov/issue/defining-diagnostic-error-scoping-review-assess-impact-national-academies-report-improving
    March 03, 2021 - Of the sixteen included studies, only five operationalized the definition and only three studied communicating … Patients and family should be included in defining the construct of “communication to the patient.”
  18. psnet.ahrq.gov/issue/information-transfer-hospital-discharge-systematic-review
    February 21, 2015 - This systematic review included 19 studies assessing the transfer of information at hospital discharge … contained patient demographics, admission/discharge dates and primary diagnoses, but less frequently included
  19. psnet.ahrq.gov/issue/barriers-and-facilitators-implementing-interventions-reducing-avoidable-hospital-readmission
    April 25, 2018 - Frequently cited barriers included limited resources, poor team communication, and complicated intervention … processes; common facilitators included leadership support, a positive organizational culture, and
  20. psnet.ahrq.gov/issue/clinician-identified-problems-and-solutions-delayed-diagnosis-primary-care-prioritize-study
    December 14, 2016 - The main issues included inability to meet patients' care needs and inadequate communication between … The top solutions included improving training of primary care doctors and enhancing communication among

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