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9001. Looking for Meds in All the Wrong Places | PSNet
      psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
      June 16, 2021 - The Commentary Patients who present to the emergency department (ED) are highly vulnerable to medication … Patient safety—the role of human factors and systems engineering. … Improving patient care. The cognitive psychology of missed diagnoses. … November 23, 2016 The missing evidence: a systematic review of patients' experiences … April 5, 2016 Patients' reports of adverse events: a data linkage study of Australian

9002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37966/psn-pdf
      January 15, 2009 - electronic medical records in primary care: lessons learned from health information systems implementation experience … electronic medical records in primary care: lessons learned from health information systems implementation experience … regarding adoption of health information systems in primary care and assessed whether quality and patient

9003. In Conversation With... Katie J. Suda, PharmD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
      December 07, 2020 - As a result, dentists are not only in charge of providing patient care, they’re also the boss. … medical doctors to provide infection prophylaxis patients prior to dental visits, such as for patients … My team randomized a cohort of patients to look at the impact of a brief pre-visit intervention in patients … Further, dentists’ access to other aspects of the patient medical record can vary greatly. … https://www.ada.org/resources/practice/practice-management/patients/educate-patients-about-addictive-qualities-of-painkillersn

9004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42685/psn-pdf
      December 06, 2013 - An AHRQ WebM&M perspective reveals a nurse's experience with MRSA. … https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature https://psnet.ahrq.gov/perspective … /interpreting-patient-safety-literature https://psnet.ahrq.gov/issue/interrelationship-isolation-precautions-and-adverse-events-acute-care-facility … https://psnet.ahrq.gov/issue/unexpected-hypoglycemia-critically-ill-patient https://psnet.ahrq.gov/issue … /health-care-associated-infections https://psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa

9005. In Conversation with…Janet Corrigan, PhD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
      April 01, 2010 - disincentives in our current payment programs that make it difficult to coordinate care for chronically ill patients … Practices were deemed to be universally applicable in clinical care settings to reduce the risk of harm to patients … intensivist staffing, comprehensive pharmacist involvement in medication management, and referral of patients … In the absence of a national approach to quality/safety measurement, local or regional stakeholders experience … The long road to patient safety: a status report on patient safety systems.

9006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837958/psn-pdf
      December 01, 2021 - When the patient arrived at 19:40, the ED was severely impacted with a high volume of patients in the … waiting room and multiple boarding patients awaiting inpatient beds. … to an ED unless the patient refuses care at the scene.10 Although most ambulance patients require ED … safety, patient experience, and the morale of hospital staff. … Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care.

9007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33821/psn-pdf
      December 01, 2016 - identify, understand, and act on the early signs of emerging problems before those risks cause harm to patients … Setting aside the radical differences between the work of treating patients and transporting passengers … Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years … Learning from patient safety incidents: creating participative risk regulation in healthcare. … Boston, MA: National Patient Safety Foundation; 2015.

9008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49846/psn-pdf
      November 01, 2018 - Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. … by experienced clinicians; (iii) but experience must emerge in trainees who start without experience … ; and (iv) experience requires the active care of patients. … While they deserve adequate guidance, progression to unsupervised practice may require that they experience … , experience with learners, propensity to trust).(5,6) Challenging learners to engage in new clinical

9009. Patient Safety in Medical, Nursing, and Other Clinical Education | PSNet
      psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
      January 31, 2020 - of patient safety. … Engage patients and families in QIPS efforts. … multifaceted programs that incorporate several different learning approaches and authentic experiences with patients … Engaging with patients and families to share information, disclose errors and improve care. … Safety in Frail Older Patients November 26, 2019 Perspectives

9010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43239/psn-pdf
      June 11, 2014 - cycle-redemption-medical-error-disclosure-and-apology-program Clinicians who are involved in a medical error and experience … cycle-redemption-medical-error-disclosure-and-apology-program https://psnet.ahrq.gov/issue/medical-error-second-victim https://psnet.ahrq.gov/issue/improving-patient-family-and-clinician-experience-after-harmful-events-when-things-go-wrong

9011. In Conversation with...Dean Schillinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
      March 01, 2009 - The most salient and consistent problem I experience as a provider is the issue of communication barriers … The whole concept of patient-centered care is that the patient is at the center of her care. … Which might you do with all your patients? DS: Let me start with the individual patient. … In general, health care encounters should promote discussion between the provider and patient, and patients … Health Literacy and Patient Safety: Help Patients Understand. Manual for Clinicians, 2nd ed.

9012. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50701/psn-pdf
      November 26, 2019 - We spoke with her about patient safety concerns when caring for frail older patients.   Dr. … older patients? … It is helping patients re-set their priorities as they get older and while not every patient is able … KH: Can this approach be used for other patient populations too, or is it just for frail older patients … KH: Besides medications, are there other patient safety topics related to frail older patients that you

9013. The Dangerous Detour | PSNet
      psnet.ahrq.gov/web-mm/dangerous-detour
      November 28, 2018 - false negative assessments pose direct threats, as patients may receive inadequate protections. … Supervision of suicidal patients in adult inpatient units in general hospitals. … Identifying and Treating Suicidal Patients in a General Medical Setting. … May 4, 2022 Design of a safety dashboard for patients. … in patient safety.

9014. Preventing wrong-site surgery in Minnesota: a 5-year journey. | PSNet
      psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey
      December 19, 2007 - Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. … Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. … The Massachusetts experience. … June 13, 2011 Debriefing for patient safety. … July 30, 2014 Eight-year experience with a neurosurgical checklist.

9015. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72587/psn-pdf
      December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability … Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability … Intrahospital transport of critically ill pediatric patients.  … Jt Comm J Qual Patient Saf. 2011;37(6):274-284.  12. … Improving the handover and transport of critically ill pediatric patients. 

9016. Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use | PSNet
      psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
      September 13, 2023 - Key elements of the system include the following:  Collection of client information: Home care … staff collect health information from the client, including vital signs (e.g., blood pressure, pulse … the medication's dose and frequency as actually taken by the client and updates the medication list … The positive experience resulting from this nurse-pharmacist collaboration prompted working with Vanderbilt … A model for improving medication use in home health care patients.

9017. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33845/psn-pdf
      November 01, 2017 - patient safety. … RW: What are the risks to patient safety of patients becoming more engaged through digital tools, particularly … want to be that difficult patient. … https://psnet.ahrq.gov/issue/connecting-patients-and-clinicians-anticipated-effects-open-notes-patient-safety-and-quality … I think patients acting as their own safeguards is an underrepresented space in patient safety right

9018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37344/psn-pdf
      March 28, 2012 - Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience … Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience … introduction-obstetric-specific-medical-emergency-team-obstetric-crises- implementation-and Implementation of rapid response systems is designed to improve patient

9019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41193/psn-pdf
      August 02, 2012 - found that children in hospitals with high reliance on Medicaid reimbursements are more likely to experience … In addition, pediatric inpatients with Medicaid are more likely than privately insured children to experience … medicaid-hospital-financial-stress-and-incidence-adverse-medical-events-children https://psnet.ahrq.gov/issue/does-patients-payer-matter-hospital-patient-safety-study-urban-hospitals

9020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47189/psn-pdf
      August 17, 2018 - Association of opioid-related adverse drug events with clinical and cost outcomes among surgical patients … Patients receiving higher dose and longer duration of opioids were more likely to experience adverse … mortality risk, and a higher rate of readmissions compared to those who did not experience problems … The authors call for reducing opioid use in acute care, postoperative settings in order to improve patient … psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications