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psnet.ahrq.gov/issue/principles-conservative-prescribing
April 22, 2017 - Strategies to prevent medication errors are an ongoing focus in patient safety. … prescribing, maintain heightened awareness about side effects, exercise skepticism about new drugs, work with patients … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … June 27, 2018
A prescription for enhancing electronic prescribing safety. … 31, 2022
Annual Perspective
Pharmacist Role in Patient
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psnet.ahrq.gov/issue/effect-us-drug-enforcement-administrations-rescheduling-hydrocodone-combination-analgesic
August 04, 2021 - observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient … July 1, 2016
Patient safety after implementation of a coproduced family centered communication … December 19, 2018
View More
Related Resources
Patient … Safety Primers
Opioid Safety
December 15, 2024
Safety Considerations … September 9, 2020
FDA recommends health care professionals discuss naloxone with all patients
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psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center
February 10, 2021 - Based on findings from their Patient Safety Learning Laboratory , the authors used human factors engineering … Perspective
Surveillance Monitoring to Improve Patient … Patient Safety
March 29, 2023
Health system redesign of cardiac monitoring … oversight to optimize alarm management, safety, and staff engagement. … Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients
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psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
October 09, 2024 - Jt Comm J Qual Patient Saf. 2024;50(12):857-866. doi:10.1016/j.jcjq.2024.08.005. … Jt Comm J Qual Patient Saf . 2024; 50 (12) :857-866 . … patients without SSI. … August 4, 2021
Advancing the science of patient safety. … September 20, 2011
The top patient safety strategies that can be encouraged for adoption
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psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors
December 02, 2020 - May 1, 2019
Computerized prescriber order entry–related patient safety reports: analysis … Safety in the Ambulatory Care Setting
August 5, 2022
When no news is bad news … : improving diagnostic testing communication through patient engagement. … health information technology interventions to improve medication laboratory monitoring for ambulatory patients … View More
See More About The Topic
Health Care Providers
Quality and Safety
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psnet.ahrq.gov/issue/reductions-sepsis-mortality-and-costs-after-design-and-implementation-nurse-based-early
March 09, 2016 - March 9, 2016
Communication with patients and families regarding health care-associated … August 12, 2020
Filling a gap in safety metrics: development of a patient-centred framework … May 29, 2024
Patient Safety Innovations
Remote Response … Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients … January 9, 2011
Patient-safety and quality initiatives in the intensive-care unit.
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psnet.ahrq.gov/issue/nursing-bedside-clinical-handover-integrated-review-issues-and-tools
July 07, 2021 - safety practices. … June 9, 2021
Information concerning ICU patients’ families in the handover—the clinicians … safety: a systematic review. … May 26, 2021
View More
Related Resources
Patient Safety … Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients
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psnet.ahrq.gov/node/837976/psn-pdf
August 31, 2022 - The study team also
found that patient safety events were highest during the summer, but these were
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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - proprietary reviews of proposed names, trademarks, packaging, and labeling for pharmaceutical industry clients … safety incident data. … safety. … across health, social care and patient safety: a systematic review of reviews. … February 12, 2020
How can patient-held lists of medication enhance patient safety?
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psnet.ahrq.gov/issue/effect-postdischarge-virtual-ward-readmission-or-death-high-risk-patients-randomized-clinical
October 31, 2011 - found that a similarly intensive intervention did not reduce readmissions in a vulnerable elderly patient … March 29, 2023
Improving Usability, Safety and Patient Outcomes With Health Information … February 27, 2019
Improving patient safety and efficiency of medication reconciliation … December 6, 2017
Identifying patient safety problems associated with information technology … errors to current approaches for ensuring technology safety.
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psnet.ahrq.gov/issue/clinical-diagnoses-and-autopsy-findings-discrepancies-critically-ill-patients
March 09, 2022 - was alive in 7.5% of patients. … safety incidents with harm in primary care. … June 27, 2018
Positive deviance: a new tool for infection prevention and patient safety … September 1, 2011
Using system analysis to build a safety culture: improving the reliability … October 20, 2010
Patient safety in intensive care: results from the multinational Sentinel
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - The patient experienced severe crush injuries after spending 7 hours pinned under a large vehicle while … Case (cont.): Novel Drug Misuse
Post-operatively, the patient developed renal failure; an APACHE II … with elevated APACHE scores and sepsis, the team decided to start the patient on the drug. … Novel Therapeutics
Anecdotal reports suggest drotrecogin alfa (activated) is underutilized
Cost
Safety … concerns
Failure to recognize eligible patients
Jacobi J.
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psnet.ahrq.gov/node/73206/psn-pdf
May 05, 2021 - This study examined sepsis
patient encounters at one health system two years before and two years after … suggest revising the measure with more flexible guidelines that allow clinician discretion may
improve patient … treatment-patterns-and-clinical-outcomes-after-introduction-medicare-sepsis-performance
https://psnet.ahrq.gov/issue/sepsis-quality-safety-net-hospitals-analysis-medicares-sep
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psnet.ahrq.gov/issue/practical-implementation-artificial-intelligence-technologies-medicine
March 24, 2019 - safety . … April 12, 2019
Indication-specific opioid prescribing for US patients with Medicaid or … Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients … Wachter, MD
August 1, 2015
HIPAA and patient care: the role for professional … January 14, 2011
Learning from others: legal aspects of sharing patient safety data using
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psnet.ahrq.gov/issue/introducing-second-year-medical-students-diagnostic-reasoning-concepts-and-skills-virtual
April 24, 2018 - June 14, 2017
Cutting-edge efforts in surgical patient safety. … July 2, 2019
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … December 9, 2020
Intraoperative sentinel events in the era of surgical safety checklists … June 21, 2023
Annual Perspective
Improving Diagnostic Safety … A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.
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psnet.ahrq.gov/issue/identification-and-safe-storage-look-alike-sound-alike-medicines-automated-dispensing
June 23, 2009 - October 6, 2021
Transforming the morbidity and mortality conference to promote safety … November 10, 2021
Partnering with patients and families living with chronic conditions … to coproduce diagnostic safety through OurDX: a previsit online engagement tool. … 1, 2023
Staffing, teamwork and scope of practice: analysis of the association with patient … safety in the context of rehabilitation.
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - was noted that the personnel carrying out the procedure at the bedside had not
performed the usual safety … In the current case, it is
unclear if the safety procedures mandated by the Universal Protocol were … Take-Home Points
Wrong-site errors are considered never events and represent a core patient safety problem … The current safety standard for preventing wrong-site errors includes The Joint Commission
Universal … safety.
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psnet.ahrq.gov/issue/machine-learning-enhance-electronic-detection-diagnostic-errors
December 18, 2024 - emergency care center and the safety of patient self-triage: real-life prospective evaluation. … July 10, 2024
Patient Safety Innovations
Remote Response … Help Improve Management of Sepsis
May 31, 2023
Perspectives on Safety … Annual Perspective
Technology as a Tool for Improving Patient … Safety
March 29, 2023
Automated identification of diagnostic labelling errors
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Efforts to improve the quality and safety of warfarin administration include publishing standardized … most common errors were missed or extra doses.(1)
One alternative strategy to enhance the quality and safety … Evaluation of warfarin dosing by pharmacists for elderly medical in-patients. … Use of specific indicators to detect warfarin-related adverse events. … African-American patients
3. Clinical hypothyroidism
4.
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - safety incidents, with 24% resulting in patient harm.( 3 ) Insulin errors are reported across all phases … A prospective, observational study found 178 medication errors in 192 patients over 28 observed provider … shifts.( 6 ) At least one error occurred in almost 60% of patients (37% reaching the patient), most … Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety … August 30, 2023
Patient Safety Innovations
Remote