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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - treated with oral anticoagulants are at
increased risk of hemorrhage and patients with hemorrhage … not have been administered
18
High-Risk Medications: Anticoagulation (3)
Approach to Improving Safety … and
Systems Change Needed
19
20
Approach to Improving Safety
• Hospitals should adopt systematic … changes to ensure
patients are screened for contraindications to high-risk
medications and that there … A surgical safety checklist to reduce morbidity and mortality in a global population.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - safety or quality improvement program
Goals of Root Cause Analysis
What happened
Why did it … Performing Root Cause Analysis
Establish the team
Leader from patient safety
ICU physician
ICU nursing … Acute decompensation after removing a central line: practical approaches to increasing safety in the … the fellow asked the resident whether he understood the order or had used vasopressin previously in patients … safety steps
Pharmacists not always included
Saint S.
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psnet.ahrq.gov/perspective/building-capacity-patient-safety
July 31, 2023 - Building Capacity for Patient Safety
Regina M. … While national datasets such as the AHRQ Patient Safety Indicators are helpful in benchmarking performance … Our end games are the same: to keep patients safe, right? … practices specific to the patients they are caring for as well as general safety practices that cross … to improve safety, both for patients and the workforce.
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psnet.ahrq.gov/node/47442/psn-pdf
October 03, 2018 - https://psnet.ahrq.gov/issue/speaking-safety-its-not-simple
Engaging patients and families in patient … This poll of patients
from Pennsylvania explores actions patients are likely to take to ensure their … https://psnet.ahrq.gov/issue/speaking-safety-its-not-simple
https://psnet.ahrq.gov/primer/patient-engagement-and-safety … https://psnet.ahrq.gov/issue/improvement-pennsylvania-healthcare-consumers-awareness-patient-safety … https://psnet.ahrq.gov/issue/patient-involvement-patient-safety-how-willing-are-patients-participate
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psnet.ahrq.gov/issue/physician-practice-patient-safety-assessment
April 24, 2018 - Measurement Tool/Indicator
The Physician Practice Patient Safety Assessment. … Use of a comprehensive patient safety tool in primary care practices. … Use of a comprehensive patient safety tool in primary care practices. … Safety
March 27, 2024
Patient Safety Innovations … May 23, 2018
Patient Safety and the Invitational Conference on Contemporary Surgical
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psnet.ahrq.gov/issue/patient-safety-office-based-setting
August 20, 2018 - Commentary
Patient safety in the office-based setting. … Patient safety in the office-based setting. Plast Reconstr Surg. 2006;117(4):61e-80e. … Patient safety in the office-based setting. Plast Reconstr Surg. 2006;117(4):61e-80e. … May 28, 2015
Discussing harm-causing errors with patients: an ethics primer for plastic … November 21, 2012
Patient safety in plastic surgery.
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psnet.ahrq.gov/issue/tamper-resistant-drugs-cannot-solve-opioid-crisis
May 01, 2019 - February 10, 2016
Fostering patient safety competencies using multiple-patient simulation … 22, 2024
Emergency physician perceptions of electronic health record usability and safety … October 14, 2020
View More
Related Resources
The Patient Safety … June 14, 2019
Reducing patient harm from opiates. … April 29, 2018
Advancing medication safety: establishing a National Action Plan for Adverse
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psnet.ahrq.gov/issue/using-stakeholder-intervention-refinement-teams-develop-approaches-real-time-integration
January 21, 2019 - Older adult patients and family caregivers face numerous safety challenges when transitioning from … May 25, 2022
Patient Safety Primers
Post-Acute Transitional … Services: Safety in Home-Based Care Programs
April 27, 2022
Patient … and Enhances Satisfaction for Elderly Patients. … August 5, 2020
Patient Safety Innovations
Team-Developed
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health … Patient safety in interventional radiology: a CIRSE IR checklist. … A checklist to improve patient safety in interventional radiology. … May 18, 2022
View More
Related Resources
Patient Safety … Safety Innovations
Preventing Falls Through Patient and Family Engagement to Create
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - safety. … safety. … Mortality among patients admitted to hospitals on weekends as compared with weekdays. … Do patient safety indicators explain increased weekend mortality? J Surg Res. 2016;200:164-170. … January 4, 2012
Shift-to-shift handoff effects on patient safety and outcomes: a systematic
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psnet.ahrq.gov/node/72725/psn-pdf
February 10, 2021 - Understanding the peer, manager, and system influence
on patient safety. … Understanding the peer, manager, and system influence on patient
safety. … https://psnet.ahrq.gov/issue/understanding-peer-manager-and-system-influence-patient-safety
A positive … safety culture can improve nursing-sensitive patient safety outcomes. … https://psnet.ahrq.gov/issue/impact-patient-safety-culture-missed-nursing-care-and-adverse-patient-events
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psnet.ahrq.gov/issue/how-do-stakeholders-experience-adoption-electronic-prescribing-systems-hospitals-systematic
December 16, 2020 - March 14, 2018
Incident reporting to improve patient safety: the effects of process variance … on pediatric patient safety in the emergency department. … safety. … December 21, 2022
The prevalence of dose errors among paediatric patients in hospital … February 22, 2019
Effects of health information technology on patient outcomes: a systematic
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Safety (SEIPS) model of work systems and patient safety ( 5 ) describes five interacting elements of … Lack of familiarity with new technology is an increasingly important patient safety problem. … Human factors systems approach to healthcare quality and patient safety. … Beyond usability: designing effective technology implementation systems to promote patient safety. … different level of care with different clinicians Chaotic ICU environment National glycemic control quality indicators
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - safety. … This question of radiology procedures at night is only one of many safety concerns that relate to off-hours … safety. … Mortality among patients admitted to hospitals on weekends as compared with
weekdays. … Do patient safety indicators explain increased weekend
mortality? J Surg Res. 2016;200:164-170.
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - Describe patient safety monitoring systems used in nursing homes. … designing such safety systems.( 18 ) The Joint Commission Patient Safety Goals for Long Term Care include … Understanding Patient Safety. New York, NY: McGraw-Hill Professional; 2007. … Long Term Care: 2011 National Patient Safety Goals. The Joint Commission; January 2011. … January 17, 2024
Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital
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psnet.ahrq.gov/issue/electronic-prescribing-systems-hospitals-improve-medication-safety-multi-methods-research
November 09, 2022 - Related Resources From the Same Author(s)
Understanding factors that could influence patient … June 15, 2022
A patient safety toolkit for family practices. … Technology as a Tool for Improving Patient Safety
March 29, 2023 … electronic prescribing of subcutaneous infusions: a before-and-after study assessing the impact upon patient … safety and service efficiency.
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psnet.ahrq.gov/issue/human-factors-and-safety-analysis-methods-used-design-and-redesign-electronic-medication
April 10, 2024 - Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally … Resources From the Same Author(s)
Drug-drug interactions and actual harm to hospitalized patients … August 19, 2016
Using the WHO International Classification of patient safety framework … Technology as a Tool for Improving Patient Safety
March 29, 2023 … March 17, 2021
Role of artificial intelligence in patient safety outcomes: systematic
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psnet.ahrq.gov/issue/improving-end-life-care-information-systems-approach-reducing-medical-errors
November 04, 2015 - Safety Practices. … November 18, 2020
Patient safety threats in information management using health information … patients and their care partners: the MySafeCare application. … January 2, 2017
Potential drug interactions and duplicate prescriptions among cancer patients … safety with antineoplastics?
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psnet.ahrq.gov/node/60731/psn-pdf
July 29, 2020 - Patient feedback for safety improvement in primary care:
results from a feasibility study. … Patient feedback for safety improvement in primary care: results from a
feasibility study. … This feasibility study surveyed 1,750 patients using the primary care patient measure of safety (PC … PMOS)
tool to obtain patient feedback about the safety of their care in primary care settings. … ://psnet.ahrq.gov/perspective/update-patient-engagement-safety
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - APPROACHES TO IMPROVING PATIENT
SAFETY
16
Approaches to Improving Patient Safety (1)
• Tracheostomy … -
specific contributing factors.
17
Approaches to Improving Patient Safety (2)
• Patients dependent … Safety (5)
• Generally, the resting cuff diameter of the cuff causing the leak should be
compared … Safety (6)
• The patient in this clinical scenario was noted to have COVID-19
pneumonia. … Percutaneous tracheostomy in critically ill patients.