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www.ahrq.gov/patient-safety/reports/engage/results.html
March 01, 2017 - Few identified the health care system (e.g., issues associated with fragmentation of care or continuity … of care between acute and primary care settings) and community (e.g., issues associated with community … Table 5 provides a summary of each domain and the informant-identified safety issues within that domain … guidelines, and other empirical studies that addressed critical issues in the intersection of patient … ; Table 8 ), fragmentation issues (75.3%), diagnostic errors (39.3%), and issues around medications
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www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
March 01, 2013 - Slide 2
CUSP and Sensemaking Tools
CUSP Tools
Staff Safety Assessment
Safety Issues Worksheet … CUSP uses the Staff Safety Assessment and Status of Safety Issues Worksheet to identify defects. … Engage the senior executive in addressing the safety issues identified on the form.
Step 2. … Image of Safety Issues Worksheet for Senior Executive Partnership with three arrows pointing at it. … Engage the senior executive in addressing the safety issues identified on the form.
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www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
December 01, 2017 - What issues were raised? … Access issues - 20% Yes.
Airway risk - 20% Yes.
Beta blockers - 40% Yes. … Safety issues.
Followup:
Met with clinic staff and surgeons. … Issues identified:
Disposable light handles were changed. … Issues identified:
Outdated preference card caused delay in case.
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psnet.ahrq.gov/node/36337/psn-pdf
October 26, 2010 - Technology, governance and patient safety: systems
issues in technology and patient safety. … Technology, governance and patient safety: systems
issues in technology and patient safety. … https://psnet.ahrq.gov/issue/technology-governance-and-patient-safety-systems-issues-technology-and- … adverse events related to medical devices, equipment, and other
technologies and discuss governance issues … https://psnet.ahrq.gov/issue/technology-governance-and-patient-safety-systems-issues-technology-and-patient-safety
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psnet.ahrq.gov/node/40251/psn-pdf
June 13, 2012 - Emerging issues and challenges for improving patient
safety in mental health: a qualitative analysis … Emerging issues and challenges for improving patient safety in mental health: a
qualitative analysis … https://psnet.ahrq.gov/issue/emerging-issues-and-challenges-improving-patient-safety-mental-health- … This article describes the dominant
issues and priorities for improving patient safety in this field … https://psnet.ahrq.gov/issue/emerging-issues-and-challenges-improving-patient-safety-mental-health-qualitative-analysis
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
May 01, 2017 - (Each team member listed below either says “Yes” and states the issues or says “No Concerns” if none) … (Each team member listed below either says “Yes” and states the issues or says “No Concerns” if none) … equipment/systems issues identified should be recorded and provided to designated person so they can … be addressed and resolution shared with the unit
Postoperative concerns/issues for the team to be … (Each team member listed below either says “Yes” and states the issues or says “No Concerns” if none.
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psnet.ahrq.gov/node/42935/psn-pdf
February 12, 2014 - Socio-technical issues and challenges in implementing
safe patient handovers: insights from ethnographic … Socio-technical issues and challenges in implementing safe patient
handovers: insights from ethnographic … https://psnet.ahrq.gov/issue/socio-technical-issues-and-challenges-implementing-safe-patient-handovers … These analyses emphasize numerous contextual issues that need be
considered when creating computerized … https://psnet.ahrq.gov/issue/socio-technical-issues-and-challenges-implementing-safe-patient-handovers-insights
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight04.html
October 01, 2013 - Oregon—and how they used their CHIPRA quality demonstration grants to elevate children’s health care issues … helpful to other States that are trying to focus attention and resources on child and adolescent health issues … data can be used to obtain buy-in from policy officials, help raise awareness about pediatric health issues … Demonstration staff have pursued a range of strategies to ensure that child and adolescent health issues … is working to improve quality and reduce the costs of care for youth with serious behavioral health issues
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psnet.ahrq.gov/node/864377/psn-pdf
March 13, 2024 - patients-experiences-dental-diagnostic-failures-qualitative-study-using-social-
media
Patient safety issues … Participants identified several categories of contributing factors, including clinician issues (e.g., … poor
communication), patient issues (e.g., lack of self-advocacy), and system factors (e.g., insurance
-
psnet.ahrq.gov/node/45132/psn-pdf
July 20, 2016 - Staying silent about safety issues: conceptualizing and
measuring safety silence motives. … Staying silent about safety issues: Conceptualizing and measuring safety
silence motives. … https://psnet.ahrq.gov/issue/staying-silent-about-safety-issues-conceptualizing-and-measuring-safety- … This study found several motives explaining why employees stay silent about safety issues, including … https://psnet.ahrq.gov/issue/staying-silent-about-safety-issues-conceptualizing-and-measuring-safety-silence-motives
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www.ahrq.gov/ncepcr/communities/pbrn/registry/unc-practice-based-research-network.html
March 05, 2008 - Substance abuse (alcohol and drug abuse)
Tobacco use and smoking cessation
Children's health issues … Behavioral health
Current or Past Research Interests Comments :
Children's health issues … : HPV immunization, asthma
Women's health issues: Uterine fibroids, prevention of lower urinary tract
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psnet.ahrq.gov/node/74249/psn-pdf
January 12, 2022 - Medication safety issues with newly authorized
PAXLOVID. … https://psnet.ahrq.gov/issue/medication-safety-issues-newly-authorized-paxlovid
Emerging care practices … https://psnet.ahrq.gov/issue/medication-safety-issues-newly-authorized-paxlovid
https://psnet.ahrq.gov
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psnet.ahrq.gov/issue/hearing-patient-safety-and-quality-issues-end-stage-renal-disease-treatment
December 23, 2012 - Congressional Testimony
Hearing on Patient Safety and Quality Issues in End Stage … Citation Text:
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment. … Cite
Citation
Citation Text:
Hearing on Patient Safety and Quality Issues … Related Resources From the Same Author(s)
Oversight Hearing on Recent Patient Safety Issues
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150122/3_barbara_burke.pdf
June 09, 2012 - day’s
NLR rounding
• Additional participants include Support Services and Patient Relations
• Issues … Time
Spent
Rounding
(min)
Food
Service
Issues
*EVS
Issues
Communication /
Care
Coordination … Issues
Patient
Relations
Referrals
Floor 17 282 223 79% 74 11 7 3 0
Floor 19 300 214 71% 68
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www.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
August 01, 2014 - Health services research addresses issues of "organization, delivery, financing, utilization, patient … health and human services policy promotes locally relevant and culturally appropriate approaches to issues … Both AHRQ and the Tribes may raise issues that need to be addressed and can include discussions regarding … "As Needed" Consultations
Both AHRQ and Tribes may raise issues that need to be addressed in a formal … Written communications from AHRQ should clearly identify the issues at hand, potentially affected Tribes
-
psnet.ahrq.gov/issue/saying-sorry-some-strategies-effective-apology-within-workplace
August 11, 2021 - Issues Ment Health Nurs. 2018;39(11):980-982. doi:10.1080/01612840.2018.1507571. … Issues Ment Health Nurs . 2018; 39 (11) :980-982 . … Issues Ment Health Nurs. 2018;39(11):980-982. doi:10.1080/01612840.2018.1507571. … August 11, 2021
Ethical issues in patient safety research: a systematic review of the … September 29, 2017
Health professionals' perspectives of safety issues in mental health
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digital.ahrq.gov/ahrq-funded-projects/past-initiatives/medicaid-and-chip
January 01, 2023 - platforms for Medicaid and CHIP staff to use for exchanging up-to-date information on health IT and HIE issues … and to share their questions and experiences related to those issues. … Privacy and Security
Sustainability and Funding
Use of Health IT for Children (CHIP and Children’s Issues … Medicaid or CHIP agency staff person interested in participating in a CoP around other Health IT and HIE issues … Repository
The Medicaid and CHIP repository allows users to search for content on health IT and HIE issues
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Martin.pdf
March 01, 2004 - Equipment/Technology
Issues
Information Information Issues Research/Investigation
Issues
Fatigue … Heavy / Complicated Workload Workload
Inadequate Staffing Staffing Issues
Interpersonal Issues … Inadequate Supervision
Policy Issues Policy / Procedure Policy / Procedure
Clinical Procedure … Issues
Patient Assessment Process Issues
Patient / Family Compliance
Patient / Family Issues … Competency Experience
Educational / Training Issues Training Issues
Training / Education /
Experience
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psnet.ahrq.gov/issue/artificial-intelligence-related-safety-issues-associated-fda-medical-device-reports
May 29, 2024 - Study
Artificial intelligence related safety issues associated with FDA medical device … Artificial intelligence related safety issues associated with FDA medical device reports. … Artificial intelligence related safety issues associated with FDA medical device reports.
-
psnet.ahrq.gov/node/860731/psn-pdf
January 17, 2024 - occupational-health-and-organizational-culture-within-healthcare-setting-
challenges
Healthcare must address workforce issues … This book
is a compiled set of pre-published articles that examine issues of workforce safety and culture … naming-baby-or-beast-importance-concepts-and-labels-healthcare-safety-investigation
https://psnet.ahrq.gov/issue/issues-and-complexities-safety-culture-assessment-healthcare