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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - https://www.safetyandquality.gov.au/our-work/indicators/avoidable-hospi…
Pronovost PJ, Brotman DJ, … Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators of Quality … July 17, 2024
Improving patient safety in public hospitals: developing standard measures … May 17, 2023
Patient Safety Innovations
Enhancing Support … Safety Innovations
Project BOOST Increases Patient Understanding of Treatment and
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www.ahrq.gov/teamstepps-program/curriculum/implement/pre/measure.html
January 01, 2024 - patient safety among leadership and staff, you may focus on changes in culture. … While staff perceptions of the safety culture are important, patient perceptions are also vital to track … You can use data from patient experience surveys or information from patient or family advisory groups … to see how patients perceive an organization’s commitment to safe and high-quality care. … In discussing Slide 19, "AHRQ Patient Safety Indicators," you may (if it’s relevant) want to note that
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/culture-checkup-tool.html
July 01, 2023 - Improving safety culture in a patient care area takes time. … No matter what instrument you use to assess patient safety culture, your results provide a snapshot of … the various climates in your patient care area, including safety climate, teamwork climate, perceptions … Safety Culture) based on a unit’s assessment of patient safety culture rather than the summary scores … Review the unit patient safety culture assessment (e.g., Hospital Survey on Patient Safety Culture) results
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Tupper_73.pdf
March 20, 2008 - Strategies for Improving Patient Safety in Small Rural Hospitals
Strategies for Improving Patient Safety … sufficient volume of events (e.g., unexpected deaths) necessary for using many quality
improvement indicators … patient safety areas. … Patient safety intervention self-assessment results
Participating hospital
Patient safety interventions … Patient Safety Demonstration.
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety … "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. … "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. … Bedside Ultrasonography Guidelines for Critically Ill Patients. … "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - Because of decreasing oxygen levels and worsening mental status, the patient required transfer back to … Indicators of tubesite during feedings. J Neurosci Nurs.
2005;37:320-325. [go to PubMed]
7. … Indicators of postpyloric feeding tube placement in
children. Crit Care Med. 2000;28:2962-2966. … National Patient Safety Agency. … Jt Comm J Qual Patient Saf. 2008;34:285-292.
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psnet.ahrq.gov/issue/patient-safety-culture-impact-workplace-violence-and-health-worker-burnout
December 07, 2022 - Patient safety culture: the impact on workplace violence and health worker burnout. … Patient safety culture: the impact on workplace violence and health worker burnout. … culture and patient safety in emergency departments: a systematic review. … March 10, 2021
Emotional safety is patient safety. … in patient safety transformation.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
January 01, 2004 - Advances in Patient Safety: Vol. 1
134
The methodology used to assess these occurrences utilized … A breakdown by
patient age revealed that the medication errors were more prevalent in patients
above … The findings raised the issue about whether these facilities are more
Advances in Patient Safety: … Sharing information among
hospitals will facilitate learning about patient safety initiatives. … Making health care safer: a critical analysis of patient
safety practices.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-051314.pptx
February 07, 2014 - They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient … Evaluate How do we know we improved safety? … Passion without direction (reach elephant without rider)
32
Engage – Patients
33
*Saint S, Ann Intern … Evaluate How do we know we improved safety? … Why do ICU patients feel ‘special’?
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www.ahrq.gov/sites/default/files/2024-01/schade-willis-report.pdf
January 01, 2024 - Final Report: Regional Patient Safety Officer Conference—Learning Together Today and Tomorrow
Conference … Key words: Patient Safety Officer, Patient Safety, Adult Learning, Social Capital
Purpose
Two substantial … What Does This
Mean to Patient Safety and How Do You Measure?” … Building a patient safety community around support and learning. … Patient Safety
InSight: The online magazine of the American Society of Professionals in Patient Safety
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlas-table41.html
March 01, 2013 - Clinical-Community Relationships Measures Instruments
Safety Check Practitioner Post-Visit Survey … Providers (GP-LI) 109
Domain
Element/Relationship
Clinic/clinician
Patient … Community resource
Clinic/clinician—patient
Clinic/clinician—community resource
Patient—community … Information technology infrastructure
**
**
**
*
*
*
Informed and activated patient … *
*
*
**
*
**
Patient experience
*
*
*
**
*
**
Proactive and ready
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/using-health-it-to-support-qi.pdf
March 01, 2015 - in its strategic plan for health IT and proposed health IT as a tool to
improve patient safety, reduce … Building on this input, OCHIN has developed a set of
common quality indicators for the collaborative … OCHIN members also use EHR-based registries and dashboards to track quality indicators
for patients … For example, the EHR-based
diabetes dashboard displays a number of key indicators, including whether … Each indicator produces a score for the patient; patients with outdated tests and health indicators
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psnet.ahrq.gov/issue/teaching-medical-students-recognise-and-report-errors
March 01, 2023 - safety. … September 1, 2007
Anticoagulation-associated adverse drug events in hospitalized patients … July 26, 2023
Patient involvement in medication safety in hospital: an exploratory study … March 16, 2023
Failure to rescue as a patient safety indicator for neurosurgical patients … February 22, 2023
"Good catch, Kiddo"--enhancing patient safety in the pediatric emergency
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Patients may also be at risk via overuse of interventions. … A rapid review of available evidence to inform indicators for routine monitoring and evaluation of respectful … Safety Threats and Challenges
Improving Patient Safety
Maternal Toolkits
Current Context
Summary … June 5, 2019
Patient Safety in Obstetrics and Gynecology. … May 29, 2019
A comprehensive obstetrics patient safety program improves safety climate
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psnet.ahrq.gov/issue/raising-barcode-improving-medication-safety-behaviours-through-behavioural-science-informed
November 01, 2023 - Study
Raising the barcode: improving medication safety behaviours through a behavioural … Raising the barcode: improving medication safety behaviours through a behavioural science-informed feedback … April 5, 2023
Comparing safety, performance and user perceptions of a patient-specific … May 8, 2017
Multiple component patient safety intervention in English hospitals: controlled … February 23, 2011
Identification of priorities for improvement of medication safety in
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Patients—outpatients, certainly, but even inpatients where possible—should know the name and purpose … Clinicians should inform patients of the dispensed or administered drug and
allow the educated patient … Printing the list of prescribed
medications for the patient can be useful, allowing patients to compare … Drug mix-ups threaten patient safety. Medscape Pharmacists.
April 29, 2008. [Available at]
2. … Effect of bar-code technology on the safety of medication
administration.
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psnet.ahrq.gov/node/43400/psn-pdf
August 13, 2014 - This retrospective study used the NSQIP indicators to identify cases of surgical site
infections. … Researchers found that nearly 50% of patients were diagnosed following hospital discharge, and
many … Patients who presented with a surgical site infection after
discharge were less likely to smoke or have … A past AHRQ WebM&M commentary discussed
environmental safety in the operating room and its relationship … effect-hospital-follow-appointment-clinical-event-outcomes-and-mortality
https://psnet.ahrq.gov/web-mm/environmental-safety-or
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psnet.ahrq.gov/issue/patient-safety-related-hospital-deaths-england-thematic-analysis-incidents-reported-national
October 31, 2014 - Study
Patient-safety–related hospital deaths in England: thematic analysis of incidents … Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national … Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national … July 3, 2016
Can patient safety incident reports be used to compare hospital safety? … June 8, 2011
View More
Related Resources
Partnership for Patients
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20131008_cg/mythbustingwebcast.pdf
October 01, 2013 - Massachusetts
General Physicians Organization
Liza Nyeko, Program Manager, the Center for Quality and Safety … Many patients are on it and sometimes it is a
family member of a patient or someone who has contact … Liza has worked for the Center for Quality and Safety of MGH and the Physician Organization as a Manager … We will select specific indicators and establish targets and we do that collaboratively. … Rick and Liza, how did MGH choose the three focus indicators?
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psnet.ahrq.gov/issue/screening-adverse-drug-events-randomized-trial-automated-calls-coupled-phone-based-pharmacist
June 05, 2018 - with the option of transfer to a live pharmacist on detecting potential adverse drug events for patients … June 5, 2018
Computerized prescriber order entry–related patient safety reports: analysis … May 10, 2017
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … December 2, 2020
Lessons learned implementing a complex and innovative patient safety … June 16, 2019
Post-discharge medication reviews for patients with heart failure: a pilot