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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - medical care that was not consistent with their preferences.( 3 ) Medical care that is inconsistent … costs, and worse ratings of care experience.( 2-4 ) Care inconsistent with patient goals also occurs … How often is end-of-life care in the United States inconsistent with patients' goals of care? … Variability among US intensive care units in managing the care of patients admitted with preexisting … Recommendations for end-of-life care in the intensive care unit: a consensus statement by American College
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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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Hospitals
Health Care
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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.
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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/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
March 27, 2024 - Ransomware attacks can impact any component of care delivery and operational functions. … IT allows the clinical staff to deliver patient care efficiently. … Cyber Insecurity in Healthcare 2023: The Cost and Impact on Patient Safety and Care . … https://aspr.hhs.gov/cyber/Documents/Health-Care-Sector-Cybersecurity-Dec2023-508.pdf
3. … of a communication and optimal resolution program in acute care hospitals.
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psnet.ahrq.gov/node/33596/psn-pdf
January 29, 2025 - Theory
The concept of failure-to-rescue (FTR) captures the idea that many complications of medical care … Failure to rescue in surgical patients: a review for
acute care surgeons. … Failure to rescue: a quality indicator for postoperative care. … Med Care. 1992;30(7):615-629. [
Free full text]
10. Ward ST, Dimick JB, Zhang W, et al. … Crit Care Explor. 2022;4(9):e0744. [Free full text]
12. Barboi C, Tzavelis A, Muhammad LN.
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care … Value and Quality of Care
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Download … The Nudge Unit at Penn Medicine focuses on a range of different care improvement projects, including … Nudges in clinical care can focus on both clinician and patient behaviors. … Key insights on launching a Nudge Unit within a health care system.
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - reported 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 dating … 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 … See More About The Topic
Residents
Emergency Departments
Labor and Delivery
Health Care
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psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - status was known by all of the relevant care providers. … training.( 11 ) Let's review the points of care where the error could have been prevented. … errors because health care providers often override electronic alerts.( 14,15 ) In the end, it was … across the continuum of care. … The current FDA categories for medication use in pregnancy may not fit all of health care providers'
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - The patient was resuscitated, transferred to the intensive care unit, and received massive transfusions … Passing important information between the care team is difficult to achieve reliably. … In health care, they are frequently used to help remind teams of important safety, team, or procedural … Surgical safety checklists, like many health care improvement tools, could benefit from regular review … The formulation and documentation of an antithrombotic plan is a key indicator of care quality.
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - Bias and the use of stigmatizing language can compromise patient care. … using standardized handoffs can help mitigate racial bias and improve the delivery of safe, equitable care … Assessing patient work system factors for medication management during transition of care … Bias and the use of stigmatizing language can compromise patient care. … Ageism can negatively impact a person’s healthcare experience and the quality of care they receive.
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - partners in their ongoing care. … , given the benefits of coordinating care and reducing barriers to care access, like transportation. … and uptake of care at home that would normally be provided in inpatient acute care settings. … While there were challenges in meeting the needs of home-based care, the demand for outpatient care … and care were deeply disrupted.
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - and care were deeply disrupted. … We’ve seen sizeable shifts to alternative models of care and locations of care delivery, with the use … The second area is meaningful patient and family engagement in their own care, and all aspects of care … partners in their ongoing care. … and uptake of care at home that would normally be provided in inpatient acute care settings.
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psnet.ahrq.gov/primer/burnout
November 20, 2024 - in the occupational context, it is not surprising that the syndrome is widely prevalent in health care … Others have focused on the importance of changing the health care culture with respect to well-being, … Caring for the health care workers during crisis: creating a resilient organization. … May 22, 2024
Burnout in Primary Care: Assessing and Addressing It in Your Practice. … Health Care Executives and Administrators
Mental Health Care (Psychiatry and Clinical Psychology
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Commentary
By Amy Nichols, EdD, RN, CNS, CHSE, ANEF
The phenomenon of leaving the care setting … of patients who are angry, agitated and unhappy with care provided, how to reduce the frequency of AMA … Discharge against medical advice (AMA) occurs when a patient wants to leave the care setting before care … Many communication and conflict resolution techniques have been created to help care providers manage … However, the health professional’s duty to provide care does not end with an AMA discharge.
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - As with many key concepts in patient safety, this one began with work outside of health care, including … Failure to rescue in surgical patients: a review for acute care surgeons. … Failure to rescue: a quality indicator for postoperative care. … Med Care . 1992;30(7):615-629. [ Free full text ] Ward ST, Dimick JB, Zhang W, et al. … Crit Care Explor . 2022;4(9):e0744. [ Free full text ] Barboi C, Tzavelis A, Muhammad LN.
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - By selecting the specific screening tools tailored to the unique patient
and care delivery needs in … each setting—such as through brevity in an ED or tailored assessment in
specialized care—healthcare … Variation in patterns of health care before suicide: a
population case-control study. … Suicide Prevention in Health Care Facilities Environmental Safety Recommendations. … Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe.