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2801. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
      May 19, 2003 - Advances in Patient Safety: Vol. 3 324 Introduction The Harvard Medical Practice Study, an interdisciplinary … safety. … Advances in Patient Safety: Vol. 3 330 These four data items should be sufficient to determine whether … Safety: Vol. 3 332 heparin about the new process. … The nature of adverse events in hospitalized patients.

2802. Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration | PSNet
      psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
      October 30, 2024 - Implementation of this innovation resulted in improved patient safety and quality for patients at high … Innovation Patient Safety Focus The innovation uses an early detection alert system to identify patients … Failure to identify, communicate, or act on indicators of acute deterioration of hospitalized patients … Summary July 23, 2024 Patient Safety Innovations … Safety in Acute Hospital Care Units April 26, 2023 Patient Safety

2803. Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare. | PSNet
      psnet.ahrq.gov/issue/action-research-simulation-team-communication-and-bringing-tacit-voice-society-simulation
      April 16, 2019 - system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients … September 27, 2016 A new approach of assessing patient safety aspects in routine practice … June 26, 2019 Necessity for a pathway for "high-alert" patients. … March 23, 2011 The relationship of the emotional climate of work and threat to patient … March 16, 2011 Changes in safety attitude and relationship to decreased postoperative

2804. Safe Medication Administration: Magnesium Sulfate | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html
      July 01, 2023 - Patients with myocardial damage. … A sample process and forms for a committee review are available at the Council on Patient Safety in Women … safety. … Obstetrical accidents involving intravenous magnesium sulfate: recommendations to promote patient safety … Patients with heart block. Patients with myocardial damage.

2805. Getting to the Root of the Matter | PSNet
      psnet.ahrq.gov/web-mm/getting-root-matter
      September 01, 2005 - Getting Started The RCA team is usually led by a member of the institution’s patient safety or quality … ventilated patients, prevention of venous thromboembolism). … Asking clinicians to jump through bureaucratic hoops in the name of patient safety squanders the good … Hospital-onset infections: a patient safety issue. … December 21, 2017 Hospitalists as emerging leaders in patient safety: targeting a few

2806. Action Plan for Translating Research Into Practice: Gap Analysis and Tests of Change: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/action-plan-trip-fac-guide.html
      February 01, 2017 - on Patient Safety Culture. … This safety program is designed to improve care for mechanically ventilated patients. … Patient mobility depends on patients being awake and alert. … A significant barrier to mobilizing patients occurs when patients are under sedation. … ( The patient was sedated. ) Why was the patient sedated?

2807. Urine Culturing Stewardship in the ICU Setting Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
      April 01, 2022 - Culturing Stewardship in the ICU Setting” is part of the Agency for Healthcare Research and Quality’s Safety … Slide 2 AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI AHRQ Safety … or surgery, or the patient is granulocytopenic. … Symptoms of UTI are rarely reported in ICU patients, which can be a barrier to patient evaluation for … You can create a strong culture of safety by discussing quality pearls like culturing stewardship at

2808. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
      June 01, 2020 - Can patients report patient safety incidents in a hospital setting? A systematic review. … Patient participation: current knowledge and applicability to patient safety. … Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families: Environmental … Deriving ICD-10 codes for Patient Safety Indicators for large-scale surveillance using administrative … Patient Safety Indicators: using administrative data to identify potential patient safety concerns.

2809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866556/psn-pdf
      August 21, 2024 - sectional Digital maturity in healthcare refers to how well hospitals use digital systems to improve patient … care processes, enhance patient safety, and provide quality health care. … grade, indicating advanced patient safety outcomes. … https://psnet.ahrq.gov/issue/patient-safety-informatics-criteria-development-assessing-maturity-digital-patient-safety … https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety https://psnet.ahrq.gov/issue

2810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60316/psn-pdf
      January 01, 2021 - Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United … Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United … https://psnet.ahrq.gov/issue/hospital-acquired-conditions-reduction-program-patient-safety-and-magnet … The authors found that Magnet hospitals are more likely to have lower patient safety indicator (PSI) … https://psnet.ahrq.gov/issue/hospital-acquired-conditions-reduction-program-patient-safety-and-magnet-designation-united

2811. Healthcare management strategies: interdisciplinary team factors. | PSNet
      psnet.ahrq.gov/issue/healthcare-management-strategies-interdisciplinary-team-factors
      November 13, 2011 - July 13, 2010 Patient-clinician diagnostic concordance upon hospital admission. … through the patient TIPS model. … October 28, 2020 Overview of progress on patient safety. … May 1, 2019 Quality and Safety in Women's Health Care. Second Edition. … December 14, 2016 Medical Errors and Safety Systems.

2812. Personal Health Records and Elder Medication Use Quality (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017034-chrischilles-final-report-2011.pdf
      January 01, 2011 - adherence, patient- and physician-centric medication quality indicators, patient self-efficacy for … To compare patient-reported MTM behaviors, medication adherence, and quality indicators among those … We adapted four general medication use patient quality indicators from the ACOVE project(27) and displayed … awareness of medication safety issues. … Quality Indicators for Medication Use in Vulnerable Elders.

2813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42439/psn-pdf
      November 23, 2016 - Guide to Patient and Family Engagement in Hospital Quality and Safety. … https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety Studies … This failure to provide patient-centered care indicates a need for increased patient engagement in safety … https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety https:// … https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety

2814. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
      June 01, 2018 - Chartbook on Health Care for Blacks Part 3: National Quality Strategy Priority—Patient Safety … Safety is the first of six National Quality Strategy (NQS) Priorities to be covered by this chartbook … , Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008-2013, and AHRQ Quality Indicators … Groups With Disparities: In all years, Hispanic patients and Black patients had higher rates of … Although patient safety initiatives focus mainly on inpatient hospital events, adverse effects of medical

2815. Making It Work Tip Sheet: Empowering Nurses To Implement Nurse-Driven Protocols for Reducing CAUTI in the ICU Setting (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/empowering-nurses.pdf
      April 01, 2022 - Empowering Nurses To Implement Nurse-Driven Protocols for Reducing CAUTI in the ICU Setting AHRQ Safety … bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) and improve safety … nurses feel empowered to utilize protocols that result in early removal of catheters and improved patient … attempt to void results in indwelling catheter being reinserted too soon. 2 AHRQ Safety … Those six additional CAUTIs over the last year led to additional patient harm.

2816. Patient Safety Organization: Change of Listing Information (pdf file)
      pso.ahrq.gov/sites/default/files/wysiwyg/PSO_ChangeOfListingInfo.pdf
      September 30, 2024 - Patient Safety Organization: Change of Listing Information Form Approved OMB … Control No: 0935-0143 Exp. date: 09/30/2024 PATIENT SAFETY ORGANIZATION: CHANGE OF LISTING INFORMATION … The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorizes the creation … of Patient Safety Organizations (PSOs). … Safety Act and Patient Safety Rule dealing with PSO operations.

2817. Patient safety in the office-based setting. | PSNet
      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.

2818. The Physician Practice Patient Safety Assessment. | PSNet
      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

2819. Hospital Survey on Patient Safety Culture: User's Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-user-guide.pdf
      July 01, 2018 - Hospital Survey on Patient Safety Culture: User's Guide HOSPITAL SURVEY ON PATIENT SAFETY CULTURE … PATIENT SAFETY USER’S GUIDE AHRQ Hospital Survey on Patient Safety Culture: User’s Guide Prepared … Patient Safety Culture Composites The Hospital Survey on Patient Safety Culture emphasizes patient safety … Current survey research also suggests that for short surveys, progress indicators (e.g., a progress … overall grade on patient safety

2820. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)
      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.