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psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
April 17, 2024 - Resources From the Same Author(s)
Associations between organizational communication and patients … October 27, 2021
Interhospital transfer patients discharged by academic hospitalists … June 21, 2016
Talking with patients about other clinicians' errors. … June 19, 2024
Contextual factors influencing the implementation of a multifaceted intervention … to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case
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www.ahrq.gov/ncepcr/reports/grants-transform/bibliography/index.html
February 01, 2017 - Patient-centered medical home among small urban practices serving low-income and disadvantaged patients … Specialty use among patients with treated hypertension in a patient-centered medical home. … Reassigned patients were younger, less sick, and had shorter pre-existing patient-doctor relationships … After adjusting for baseline patient differences, patients at the PCMH clinic reported significantly … After adjusting for baseline, PCMH patients reported higher ratings on six of seven patient experience
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
May 01, 2015 - Patient-centered medical home among small urban practices serving low-income and disadvantaged patients … Specialty use among patients with treated hypertension in a patient-centered medical home. … Reassigned patients were younger, less sick, and had shorter pre-existing patient-doctor relationships … After adjusting for baseline patient differences, patients at the PCMH clinic reported significantly … After adjusting for baseline, PCMH patients reported higher ratings on six of seven patient experience
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psnet.ahrq.gov/issue/why-learning-patient-safety-incidents-still-so-hard-sociocultural-perspective-learning
June 29, 2011 - Why is learning from patient safety incidents (still) so hard? … Why is learning from patient safety incidents (still) so hard? … Association of opioid-related adverse drug events with clinical and cost outcomes among surgical patients … May 13, 2020
The effects of harm events on 30-day readmission in surgical patients. … November 8, 2023
Contextual factors influencing the implementation of a multifaceted
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psnet.ahrq.gov/issue/prospective-study-multisite-spread-medication-safety-intervention-factors-common-hospitals
April 24, 2018 - Organizational context can serve as a driver or barrier to the implementation of patient safety interventions … This qualitative study identified several contextual factors impacting the implementation of the pharmacist-driven … July 29, 2020
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … adverse events, adverse drug events, and quality of life in older patients: an observational study. … March 30, 2022
Antibiotic prescribing errors in patients discharged from the pediatric
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psnet.ahrq.gov/issue/towards-diagnostic-excellence-academic-ward-teams-building-conceptual-model-team-dynamics
August 20, 2018 - medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual … August 20, 2018
Prevalence and causes of diagnostic errors in hospitalized patients under … February 12, 2020
Effects of resident duty hour reform on surgical and procedural patient … safety indicators among hospitalized Veterans Health Administration and Medicare patients. … February 7, 2024
Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad
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psnet.ahrq.gov/issue/explaining-organisational-responses-board-level-quality-improvement-intervention-findings
November 21, 2017 - The authors highlight the importance of focusing on these contextual factors when seeking improvement … February 7, 2018
Codifying knowledge to improve patient safety: a qualitative study of … patient safety in the NHS: learning lessons from other parts of the public sector? … November 10, 2021
Management and patient safety of complex elderly patients in primary … surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients
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psnet.ahrq.gov/issue/complications-surgeons-notes-imperfect-science
January 13, 2010 - Part I, Fallibility, explores several patient safety issues. … March 20, 2019
Every Patient Tells A Story: Medical Mysteries and the Art of Diagnosis … October 18, 2023
Listening for What Matters: Avoiding Contextual Errors in Health Care … February 6, 2019
Overkill: An avalanche of unnecessary medical care is harming patients … February 5, 2020
Surgical Patient Safety: A Case-Based Approach.
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www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar03/logicmodelsl.html
July 01, 2013 - Slide 3 The Logic Model: A Foundation to Implement, Study, and Refine Patient-Centered Medical Home ( … Logic Models: The Foundation to Implement, Study, and Refine Patient-Centered Medical Home Models. … Contextual factors that may influence the intervention’s ability to produce results. … What contextual factors are likely to affect the process? … Affect change on multiple levels (patients, providers, practices, health systems).
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/intro.html
November 01, 2017 - High-Risk Report
Summary of Fall Risk Factors (by Unit or Facility, quarterly or monthly)
Contextual
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digital.ahrq.gov/ahrq-funded-projects/use-ehr-metadata-assess-hospital-discharge-planning-post-acute-transitions
January 31, 2025 - Incomplete discharge planning puts patients at increased risk of care disruption, complications, and … adverse health events, resulting in nearly one in four patients being readmitted. … research are as follows: Characterize task and workflow variation as clinicians prepare information for patient … Identify measures of the discharge planning process that are associated with patient outcomes. … They will then descriptively analyze key patient and contextual factors that drive this variation and
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psnet.ahrq.gov/issue/use-novel-modified-fishbone-diagram-analyze-diagnostic-errors
February 13, 2019 - November 18, 2013
Seen through their eyes: residents' reflections on the cognitive and contextual … July 2, 2014
Implementation of bar-code medication administration to reduce patient harm … July 14, 2021
Surgeon and surgical trainee experiences after adverse patient events. … 19, 2024
What every graduating resident needs to know about quality improvement and patient … September 18, 2013
Patient safety strategies targeted at diagnostic errors: a systematic
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psnet.ahrq.gov/issue/judgment-under-uncertainty-heuristics-and-biases
June 02, 2010 - March 6, 2005
Oxford Professional Practice: Handbook of Patient Safety. … July 27, 2022
Around the Patient Bed: Human Factors and Safety in Health Care. … January 27, 2021
Listening for What Matters: Avoiding Contextual Errors in Health Care … July 13, 2016
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us … September 30, 2015
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Related Resources
Patient
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digital.ahrq.gov/ahrq-funded-projects/systematic-design-meaningful-presentations-medical-test-data-patients
January 01, 2023 - Care
Patient Engagement
Advances in patient-centered care and health information technology … (IT) mean that most patients have access to laboratory tests. … needs, barriers to patient data use, and potential solutions for development and testing. … results to patients. … they found that the data can be made more intuitive through visual design and inclusion of relevant contextual
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psnet.ahrq.gov/issue/ethical-duty-health-care-systems-address-interfacility-medical-error-discovery
September 11, 2019 - RIS
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Related Resources From the Same Author(s)
Patient … The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient … June 7, 2017
Understanding context specificity: the effect of contextual factors on clinical … July 25, 2018
Medical Office Survey on Patient Safety Culture: 2018 User Database Report … May 2, 2018
Leadership oversight for patient safety programs: an essential element.
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/osteoporosis-screening-june-2018
November 05, 2015 - The framework starts on the left with the patient population of interest. … Contextual Questions
Contextual … What is the evidence from modeling studies about different fracture risk thresholds for identifying patients
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www.ahrq.gov/news/newsroom/press-releases/state-based-health-extension-cooperatives.html
September 01, 2024 - managed care organizations; clinicians and staff from safety-net health care delivery organizations; and patients … extension services vary across Cooperatives, assess the impact and equity of these models, identify contextual … AHRQ's Healthcare Extension Service is funded through a major investment from the Patient-Centered Outcomes … This initiative addresses the Patient-Centered Outcomes Research Trust Fund Strategic Framework’s mission … priorities and aligns with AHRQ's broader and unique scientific mission of improving the quality of care patients
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www.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
April 01, 2025 - of contextual factors. … The combination of emerging patient safety threats and the growing amount of published patient safety … Journal of Patient Safety and Risk Management 2024 Aug 28 Patient and Family Engagement (Oct. 30, 2023 … Journal of Patient Safety and Risk Management 2024 August 21 Patient Monitoring Systems To Prevent Failure … Within-Unit Transitions (January 16, 2025) Report Protocol Programs for Responding to Harms Experienced by Patients
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/genital-herpes-serologic-screening
December 02, 2021 - Contextual Questions
Contextual … herpes or reduce risk for transmission
KQs 5, 6: Behavioral counseling interventions, including patient … Behavioral counseling interventions vs. attention controls or usual care care (e.g., provision of a patient
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kaplan-b-2001
January 01, 2001 - (RCT) to assess system performance or to focus on changes in clinical performance that could affect patient … field tests of a CDSS and almost none use a naturalistic design in routine clinical settings with real patients … little theoretical discussion, although papers are permeated by a rationalist perspective that excludes contextual … "Reminders, alerts, treatment plans, and patient education, have been reported as effective in changing