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psnet.ahrq.gov/issue/engineering-system-communication-safer-surgery
January 18, 2013 - An observational study of the frequency, severity, and etiology of failures in postoperative care … January 18, 2013
An evaluation of information transfer through the continuum of surgical care … August 11, 2010
Failures in communication and information transfer across the surgical care … A systematic quantitative assessment of risks associated with poor communication in surgical care … 21, 2009
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Operating Room
Health Care
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psnet.ahrq.gov/issue/consequences-hindsight-bias-medical-decision-making
July 14, 2010 - September 5, 2012
Making Health Care Safer II: An Updated Critical Analysis of the Evidence … August 4, 2021
Racial differences in antibiotic prescribing by primary care pediatricians … July 2, 2014
Twelve tips on engaging learners in checking health care decisions.
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psnet.ahrq.gov/issue/improving-patient-understanding-prescription-drug-label-instructions
April 16, 2010 - View More
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Ambulatory Clinic or Office
Health Care … Providers
Family Medicine
Primary Care
General Internal Medicine
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psnet.ahrq.gov/node/45365/psn-pdf
August 03, 2016 - Workarounds and test results follow-up in electronic
health record–based primary care. … Workarounds and Test Results Follow-up in Electronic Health
Record-Based Primary Care. … //psnet.ahrq.gov/issue/workarounds-and-test-results-follow-electronic-health-record-based-primary-
care … should be improved in future electronic health records and work systems to enhance
efficiency and care … https://psnet.ahrq.gov/issue/workarounds-and-test-results-follow-electronic-health-record-based-primary-care
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - across time and space
Test results may arrive when the ordering provider is no longer focused on the care … Issues and initiatives in the testing process in primary care physician offices. … : dissatisfaction with test result management systems in primary care. … An initiative to improve the management of clinically significant test results in a large health care
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psnet.ahrq.gov/issue/or-and-just-culture
February 01, 2017 - February 1, 2017
Field test results of a new ambulatory care Medication Error and Adverse … April 12, 2011
Artificial intelligence in the provision of health care: an American College … June 12, 2024
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … September 22, 2021
Crowding in the Emergency Department: Challenges for the Care of Children
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - from both sides:
Industry was concerned that the regulations would "bankrupt" or "paralyze" health care … these unintended practices in day-to-day operations began to have serious implications for patient care … ) in 2009 significantly increased the electronic clinical data being collected and shared by health care … Paving the regulatory road to the "learning health care system." … 16
16
Role of the Chief Privacy Officer
HIPAA Privacy Rule requires covered health care providers
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psnet.ahrq.gov/node/44350/psn-pdf
July 29, 2015 - Reporting and using near-miss events to improve patient
safety in diverse primary care practices: a … Reporting and Using Near-miss Events to Improve Patient Safety in
Diverse Primary Care Practices: A … /psnet.ahrq.gov/issue/reporting-and-using-near-miss-events-improve-patient-safety-diverse-primary-
care-practices … describes the successful implementation of a Web-based reporting system for near-miss events
in primary care … ://psnet.ahrq.gov/issue/reporting-and-using-near-miss-events-improve-patient-safety-diverse-primary-care-practices
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psnet.ahrq.gov/issue/reducing-risk-delayed-colorectal-cancer-diagnoses-through-ambulatory-safety-net-collaborative
February 28, 2011 - Ambulatory safety nets (ASNs) employ a combination of approaches (e.g., patient navigators, care coordination … , patient education, workflow redesigns) to enhance the safety of patients receiving outpatient care. … 30, 2024
Patient safety in actioning and communicating blood test results in primary care … : a UK wide audit using the Primary Care Academic CollaboraTive (PACT). … View More
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Ambulatory Clinic or Office
Primary Care
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psnet.ahrq.gov/node/39988/psn-pdf
November 10, 2010 - Qual Saf Health Care. 2010;19(5):425-9. doi:10.1136/qshc.2008.031591.
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psnet.ahrq.gov/node/45123/psn-pdf
May 07, 2018 - Acute Care Edition. May 5, 2016;21:1-4. … reducing-potentially-fatal-errors-associated-high-doses-insulin-successful-multifaceted
https://psnet.ahrq.gov/issue/organizational-culture-team-climate-and-diabetes-care-small-office-based-practices
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psnet.ahrq.gov/issue/improving-self-reporting-adverse-drug-events-west-virginia-hospital
March 10, 2011 - March 10, 2011
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … February 11, 2009
Operational failures detected by frontline acute care nurses. … Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care
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psnet.ahrq.gov/node/45995/psn-pdf
May 24, 2017 - https://psnet.ahrq.gov/issue/patient-safety-13
https://psnet.ahrq.gov/primer/ambulatory-care-safety
https
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psnet.ahrq.gov/node/40376/psn-pdf
July 06, 2012 - Electronic prescribing in an ambulatory care setting: a
cluster randomized trial. … Electronic prescribing in an ambulatory care setting: a cluster
randomized trial. … https://psnet.ahrq.gov/issue/electronic-prescribing-ambulatory-care-setting-cluster-randomized-trial … Existing data on the use of computerized provider order entry (CPOE) in the ambulatory care setting … https://psnet.ahrq.gov/issue/electronic-prescribing-ambulatory-care-setting-cluster-randomized-trial
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psnet.ahrq.gov/node/35636/psn-pdf
June 24, 2010 - improving-papanicolaou-test-quality-and-reducing-medical-errors-using-toyota-production
https://psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
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psnet.ahrq.gov/issue/stay-connected-faqs-about-small-bore-connectors-and-tubing-misconnections
March 12, 2016 - Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care … at the Phoenix VA Health Care System in Arizona. … February 12, 2020
An asset-based quality improvement tool for health care organizations … : cultivating organization wide quality improvement and health care professional engagement. … More About The Topic
Outpatient Surgery
Hospitals
Ambulatory Clinic or Office
Health Care
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psnet.ahrq.gov/node/43679/psn-pdf
May 22, 2015 - patient-safety-goals-proposed-federal-health-information-technology-safety-center
https://psnet.ahrq.gov/issue/health-it-and-patient-safety-building-safer-systems-better-care
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psnet.ahrq.gov/node/45029/psn-pdf
April 20, 2016 - This review discusses sedation in the ambulatory setting and highlights how
factors related to the care … analysis-adverse-events-associated-adult-moderate-procedural-sedation-outside-operating-room
https://psnet.ahrq.gov/primer/ambulatory-care-safety
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psnet.ahrq.gov/node/43722/psn-pdf
November 26, 2014 - Nursing and
Residential Care. 2014;16(11). doi:10.12968/nrec.2014.16.11.617. … repeat-medication-errors-nursing-homes-contributing-factors-and-their-association-patient
https://psnet.ahrq.gov/issue/organizational-culture-team-climate-and-diabetes-care-small-office-based-practices
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psnet.ahrq.gov/issue/integrating-patient-safety-curriculum
July 15, 2009 - February 15, 2023
Considering the safety and quality of artificial intelligence in health care … September 16, 2020
Roadmap to Health Care Safety for Massachusetts. … Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care … July 14, 2010
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Health Care Executives … and Administrators
Educators
Nurse Care
Students