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psnet.ahrq.gov/issue/hiding-plain-sight-inconvenient-facts-patient-safety-non-247-theatre-site-staffed-obstetric
November 02, 2022 - November 2, 2022
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … May 1, 2015
Decreasing handoff-related care failures in children's hospitals. … June 28, 2010
Measuring perceptions of safety climate in primary care: a cross-sectional … February 21, 2024
Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs … September 15, 2021
Maternal and neonatal health care worker well-being and patient safety
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psnet.ahrq.gov/issue/healing-our-own-randomized-trial-assess-benefits-peer-support
May 19, 2021 - May 4, 2022
In situ simulation for adoption of new technology to improve sepsis care … resources utilization after transitions of care: a meta-analysis of randomized controlled trials. … February 15, 2023
A new index for obstetrics safety and quality of care: integrating … June 1, 2022
Psychometric properties of the perinatal missed care survey and missed care … November 25, 2020
The psychological experience of obstetric patients and health care
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psnet.ahrq.gov/primer/never-events
June 15, 2024 - setting Patient death or serious injury associated with the use or function of a device in patient care … suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting Care … death or serious injury associated with a burn incurred from any source in the course of a patient care … with introduction of a metallic object into the MRI area Potential criminal events Any instance of care … Because Never Events are devastating and preventable, health care organizations are under increasing
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. … Urgent consultations were obtained from Maternal-Fetal Medicine and Acute Care Surgery. … Measuring diagnostic errors in primary care: the first step on a path
forward. … Comment on "Types and origins of diagnostic errors in primary care settings".
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psnet.ahrq.gov/primer/high-reliability
January 29, 2020 - The concept of high reliability is attractive for health care, due to the complexity of operations and … Sometimes people interpret high reliability as meaning effective standardization of health care processes … AHRQ has outlined practical strategies for health care organizations aiming to become highly reliable … High-reliability health care: getting there from here. … 15, 2024
Patient Safety Primers
Missed Nursing Care
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psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
April 30, 2014 - A typology of electronic health record workarounds in small-to-medium size primary care … 2009
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Labor and Delivery
Health Care
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - How has the technology changed as part of managing patient care? … We have done projects with patients who have memory care issues. … Colton Hood : Correctional care could also benefit from RPM. … Medical care can be challenging in that situation. … Providers
Health Care Executives and Administrators
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - While patient safety has traditionally focused on hospital-based care, measuring ambulatory care safety … We are going to see care from their perspective. … I think it will change our perception of what is quality and safe care overall and what is quality care … we can understand care from their perspective. … Health Care Providers
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - hospital for definitive care, given the unavoidable regionalization of pediatric specialty care. … for Patient- and Family-Centered Care. … care. … Family-centered care: current applications and future directions in pediatric health care. … Factors influencing implementation of family-centered care in a neonatal intensive care unit.
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - patient was transferred to a negative pressure room, the baby was isolated in the neonatal intensive care … (personal and parental) and health care during the critical transitional period of caring for a newborn … and communication from health care staff. … Available at: https://www.fda.gov/medical-devices/letters-health-care-providers/poten… . … Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.
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psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
June 15, 2024 - Histograms can also help users identify potential improvements in processes of care. 1 , 2 As an example … As the histogram shows, several discharge summaries took more than a week to be sent to primary care … Teach-back is a strategy that involves the health care provider asking patients or family members to … explain health care instructions in their own words to confirm that they clearly understood these … July 7, 2021
Patient safety in women's health care: a framework for progress.
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - An unacceptably large proportion of patients experience preventable harm at the hands of the health care … system, and even more patients experience errors in their care that (through early detection or sheer … Despite this effort, health care institutions are still searching for
optimal methods to identify underlying … and recent commentaries have called for greater integration of
human factors principles into health care … Voluntary error reporting systems are ubiquitous in health care institutions and are an integral piece
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - Let's shift to health care. It sounds like health care was not your first gig. … Not just sick care, but health care—focused on keeping people healthy to lower the care burden and improve … Patient safety, care quality, and care coordination are highly related
When TeamSTEPPS launched 10 … deliver care. … about Surveillance Monitoring
April 26, 2023
Delivering high reliability in maternity
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psnet.ahrq.gov/web-mm/insert-omission
May 09, 2014 - Quality and patient safety metrics: developing a structured program for improving patient care … June 19, 2024
Quality measures of clinical pharmacy services during transitions of care … Resources
Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Am J Manag Care . 2022;28(1):e1-e6. [ Free full text ] De Simone S, Franco M, Servillo G, et al. … Access and quality of care in direct-to-consumer telemedicine. … July 27, 2022
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care. … February 9, 2022
The optimal use of telehealth to deliver safe patient care. … Providers
Medicine
Nurse Care
Active Errors
Latent Errors
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - education and a standardized workflow were developed to ensure that BHVS was implemented in all primary care … Individuals experiencing IPV are less likely to obtain needed medical care, keep appointments, improve … Trauma and trauma-informed care. In: Gerber MR, ed. Trauma-Informed Healthcare Approaches. … From treatment to healing: the promise of trauma-informed primary care. … From treatment to healing: inquiry and response to recent and past trauma in adult health care.
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - The application of this paradigm in health care will require that we explore strategies to effectively … Resilience and resilience engineering in health care. Jt Comm J Qual Patient Saf. 2014;40:376-383. … Resilient Health Care, Volume 2: The Resilience of Everyday Clinical Work. … Delivering Resilient Health Care. New York, NY: Routledge; 2018:210-216. … Providers
Health Care Executives and Administrators
Mental Health Care (Psychiatry and Clinical
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - medical or surgical services generally seek improved health, the systems guiding inpatient medical care … Standard order sets would minimize risk to patients and serve as the basis for care guidelines. … in the use of real-time electronic clinical data to improve the safety and reliability of their own care … Annual Perspective
Communication During Transitions of Care … 1, 2003
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See More About The Topic
Hospitals
Health Care
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psnet.ahrq.gov/node/60746/psn-pdf
July 29, 2020 - some missed periods and a positive urine pregnancy test at home but had
not received any prenatal care … Her lack of prenatal care represented a
missed opportunity to get an early ultrasound for pregnancy … errors
Appropriate supervision of physician trainees is necessary to ensure high-quality patient care … MBBS, MPH; Torretti, Dennis MD Developing Health
Care Organizations That Pursue Learning and Exploration
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psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - in an emergency department (ED) each year; most receive their care in a community hospital setting.( … A care provider may inadvertently try to use a Broselow blade with a non-Broselow handle or vice versa … Differences in the quality of pediatric resuscitative care across a spectrum of emergency departments … Pediatr Emerg Care. 2018;34:17-20. [go to PubMed]
7. … Joint policy statement—guidelines for care of children in the emergency department.