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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/web-mm/getting-right-doctor-right-away
July 01, 2011 - providers is essential for providing safe and high quality care to patients. … They can also raise health care costs. … , etc.) and first call provider (the provider on the care team responsible for direct care of the patient … Yet, identification of a patient's care team is critical to patient safety. … J Crit Care. 2006;21:236-242. [go to PubMed] 2. Sutcliffe KM, Lewton E, Rosenthal MM.
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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/node/49575/psn-pdf
November 01, 2008 - status was known by all of the relevant care providers. … the subject of improvement projects and interprofessional training.(11) Let's review the points of care … Take-Home Points
All health care providers (physicians, pharmacists, nurses, dentists, etc.) should … 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/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/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/web-mm/refused-medication-error
November 01, 2005 - Nonadherence has been estimated to cost the United States health care system between $100 billion and … barriers to safe patient care. … Priority Areas for National Action: Transforming Health Care Quality. … Oakbrook Terrace, IL: Joint Commission Center for Transforming Health Care; 2016. … Some unintended consequences of information technology in health care: the nature of patient care information
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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/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/web-mm/xl-or-smaller
September 13, 2017 - Pediatr Emerg Care. 1999;15:1-4.[ go to PubMed ] 9. … About The Topic
General Hospitals
Emergency Departments
Children's Hospitals
Health Care … Providers
Non-Health Care Professionals
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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/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/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/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/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