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  1. Module 3: Component Kit (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-component-kit.docx
    May 01, 2017 - Plan-Do-Study-Act “Ramp”: Learn To Use an Escalation Procedure for Urgent Issues 7 Example: CUS Contact … for patients on the current day, and also raise any other issues. … Supervisors have an opportunity to consider whether issues raised count as type 1 or type 2 problems … Such issues will often require dedicated, cross-functional quality improvement initiatives. … Plan-Do-Study-Act “Ramp”: Learn to Use an Escalation Procedure for Urgent Issues Figure 4.

  2. AHRQ Safety Program for Perinatal Care: Shadowing Another Professional Tool (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/professional-tool.docx
    May 01, 2017 - providers often do not understand other disciplines’ daily responsibilities, teamwork, and communication issues … Review this tool before your shadowing experience to help you recognize teamwork and communication issues … Below is a framework to help you identify communication and teamwork issues that affect patient care … Was one clinician approached more often for patient issues? … If one clinician was approached more often, what patient care issues evolved (e.g., delay in care delivery

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35833/psn-pdf
    July 23, 2010 - Medication administration errors: understanding the issues. … Medication administration errors: understanding the issues. Aust J Adv Nurs. 2006;23(3):33-41. … https://psnet.ahrq.gov/issue/medication-administration-errors-understanding-issues The authors review … the literature on medication administration errors and categorize systems and personnel issues that … https://psnet.ahrq.gov/issue/medication-administration-errors-understanding-issues

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35272/psn-pdf
    June 29, 2009 - Clinical cognition and biomedical informatics: issues of patient safety. … Clinical cognition and biomedical informatics: Issues of patient safety. … https://psnet.ahrq.gov/issue/clinical-cognition-and-biomedical-informatics-issues-patient-safety The … authors present issues related to cognition in nursing practice and how these might be applied to design … https://psnet.ahrq.gov/issue/clinical-cognition-and-biomedical-informatics-issues-patient-safety

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42343/psn-pdf
    June 19, 2013 - Top 10 patient safety issues: what more can we do? June 19, 2013 Steelman VM, Graling PR. … Top 10 patient safety issues: what more can we do? … https://psnet.ahrq.gov/issue/top-10-patient-safety-issues-what-more-can-we-do This commentary reveals … https://psnet.ahrq.gov/issue/top-10-patient-safety-issues-what-more-can-we-do https://psnet.ahrq.gov/ … issue/priority-patient-safety-issues-identified-perioperative-nurses

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842430/psn-pdf
    September 05, 2018 - The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus … The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus Development … https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-2009- consensus-development … https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-2009-consensus-development … https://psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-2009-consensus-development

  7. How the CHIPRA quality demonstration elevated children on State health policy agendas (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight04.pdf
    September 08, 2015 - 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 … not only to advance child health quality in the short term, but also to link child health quality issues … Oregon—and how they used their CHIPRA quality demonstration grants to elevate children’s health care issues … Care Act (ACA) has created an unprecedented opportunity to integrate child and adolescent health issues

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50925/psn-pdf
    February 19, 2020 - Report of the Independent Inquiry into the Issues Raised by Paterson. February 19, 2020 James G. … https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson Sharing information from … https://psnet.ahrq.gov/issue/report-independent-inquiry-issues-raised-paterson https://psnet.ahrq.gov

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36616/psn-pdf
    January 14, 2011 - Telling cultures: 'cultural' issues for staff reporting concerns about colleagues in the UK National … Telling cultures: 'cultural' issues for staff reporting concerns about colleagues in the UK National … https://psnet.ahrq.gov/issue/telling-cultures-cultural-issues-staff-reporting-concerns-about-colleagues-uk … https://psnet.ahrq.gov/issue/telling-cultures-cultural-issues-staff-reporting-concerns-about-colleagues-uk-national-health … https://psnet.ahrq.gov/issue/telling-cultures-cultural-issues-staff-reporting-concerns-about-colleagues-uk-national-health

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37624/psn-pdf
    September 27, 2017 - Adverse drug events and medication errors in psychiatry: methodological issues regarding identification … Adverse drug events and medication errors in psychiatry: methodological issues regarding identification … https://psnet.ahrq.gov/issue/adverse-drug-events-and-medication-errors-psychiatry-methodological-issues … https://psnet.ahrq.gov/issue/adverse-drug-events-and-medication-errors-psychiatry-methodological-issues-regarding … https://psnet.ahrq.gov/issue/adverse-drug-events-and-medication-errors-psychiatry-methodological-issues-regarding

  11. Application of lean thinking to health care: issues and observations. | PSNet

    psnet.ahrq.gov/issue/application-lean-thinking-health-care-issues-and-observations
    May 28, 2015 - Commentary Application of lean thinking to health care: issues and observations. … Application of lean thinking to health care: issues and observations. … Application of lean thinking to health care: issues and observations.

  12. Pharmacists and health information technology: emerging issues in patient safety. | PSNet

    psnet.ahrq.gov/issue/pharmacists-and-health-information-technology-emerging-issues-patient-safety
    November 13, 2013 - Review Pharmacists and health information technology: emerging issues in patient … Pharmacists and Health Information Technology: Emerging Issues in Patient Safety. … Pharmacists and Health Information Technology: Emerging Issues in Patient Safety.

  13. Tying up loose ends: discharging patients with unresolved medical issues. | PSNet

    psnet.ahrq.gov/issue/tying-loose-ends-discharging-patients-unresolved-medical-issues
    February 24, 2011 - Study Tying up loose ends: discharging patients with unresolved medical issues. … Tying up loose ends: discharging patients with unresolved medical issues. … Tying up loose ends: discharging patients with unresolved medical issues.

  14. Product-related issues make error potential enormous with investigational drugs. | PSNet

    psnet.ahrq.gov/issue/product-related-issues-make-error-potential-enormous-investigational-drugs
    May 07, 2018 - Newspaper/Magazine Article Product-related issues make error potential enormous with … Citation Text: Product-related issues make error potential enormous with investigational drugs. … Copy URL Cite Citation Citation Text: Product-related issues

  15. Maryland Guides Prescribers on Use of Atypical Antipsychotic Medications | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/newsroom/case-studies/coe1304.html
    April 01, 2013 - It also conducts outreach activities to prescriber groups to discuss issues involved in pediatric antipsychotic … If the information falls outside of the criteria or reveals other therapeutic issues, a child psychiatrist … follows up, discussing the issues with the treating psychiatrist. … If issues persist, an additional review with a Medicaid child psychiatrist can be requested.

  16. Briefing and Debriefing Tool | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/briefing-debriefing.html
    December 01, 2017 - ____________________________________________________________________________ Access issues: … Circulating review: Equipment availability, malfunctions, or concerns Critical issues … team: Count correct Specimens labeled correctly Clean/dirty instrument separation Equipment issues … personnel: _____________________________ Circulating nurse: _________________________________ Issues

  17. Tool: Briefing and Debriefing Tool (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/briefing_debriefing.docx
    December 01, 2017 - _____________________________________________ · Access issues: ______________________________________ … Patient-specific concerns · Circulating review · Equipment availability, malfunctions, or concerns · Critical issues … team · Count correct · Specimens labeled correctly · Clean/dirty instrument separation · Equipment issues … Anesthesia personnel: ___________________________ · Circulating nurse: ___________________________ Issues

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838914/psn-pdf
    October 26, 2022 - first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues … National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues … The formation, activities, and primary themes of safety issues are described.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60001/psn-pdf
    March 04, 2020 - issue/patient-safety-marginalised-groups-narrative-scoping-review To better understand patient safety issues … A variety of patient safety issues were identified, and half of the included studies looked at either … understand the intersection between marginalization and the multi-dimensional nature of patient safety issues

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60686/psn-pdf
    July 15, 2020 - and-its-associated-safety-related- research This review discusses the most common research on COVID-19 and safety issues … occupational safety of heath professionals, patient transport safety) and identifies several safety issues … attributable to the pandemic which have been relatively understudied, including issues around supply-chain
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