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3341. Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. | PSNet
      psnet.ahrq.gov/issue/tall-man-lettering-and-potential-prescription-errors-time-series-analysis-42-childrens
      January 12, 2012 - Even in the era of electronic prescribing , look-alike and sound-alike drug names remain a safety … April 24, 2018 An mHealth design to promote medication safety in children with medical … July 29, 2020 Changes in medication safety indicators in England throughout the covid … -19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using … Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients

3342. Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
      January 01, 2021 - safety • Develop an approach to managing patients diagnosed with pulmonary embolism including anticoagulation … safety, ACR places shared responsibility on ordering physicians for timely follow-up of diagnostic … Approach to Improving Safety 36 37 Approach to Improving Safety (1) • This case represents a classic … radiologic findings • Failure of the primary team to review imaging studies • Failure to recognize multiple indicators … safety and minimize diagnostic error

3343. Common Formats for Event Reporting - Diagnostic Safety Version 1.0 | PSNet
      psnet.ahrq.gov/issue/common-formats-event-reporting-diagnostic-safety-version-10
      December 24, 2008 - The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient … of Patient Safety Practices: Developing Criteria. … March 4, 2024 Challenge Competition: Impact of Patient Safety Tools. … and Quality April 26, 2023 AHRQ-Funded Patient Safety Project Highlights: … Improving Healthcare Safety by Engaging Patients and Families.

3344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74200/psn-pdf
      January 01, 2022 - , racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor … patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to … Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant … Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients … ://psnet.ahrq.gov/issue/sex-and-gender-differences-anesthesia-relevant-also-perioperative-safety https

3345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44586/psn-pdf
      June 21, 2016 - safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts … The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years … The remaining burden of HACs suggests continued investment in this patient safety problem is needed. … wisdom-and-justice-not-paying-preventable-complications https://psnet.ahrq.gov/issue/efforts-improve-patient-safety-result … -13-million-fewer-patient-harms-interim-update-2013 https://psnet.ahrq.gov/issue/partnership-patients

3346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73331/psn-pdf
      May 26, 2021 - cancer-diagnoses-delayed-among-prisoners-washington-state Delays and mistakes in health care for distinct patient … cancer-diagnoses-delayed-among-prisoners-washington-state https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors … https://psnet.ahrq.gov/issue/patient-safety-moving-bar-prison-health-care-standards https://psnet.ahrq.gov

3347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837332/psn-pdf
      June 08, 2022 - Influence of psychological safety and organizational support on the impact of humiliation on trainee … Influence of psychological safety and organizational support on the impact of humiliation on trainee … J Patient Saf. 2022;18(4):370-375. doi:10.1097/pts.0000000000000927. … https://psnet.ahrq.gov/issue/influence-psychological-safety-and-organizational-support-impact-humiliation … This study explored the relationship between resident psychological safety, perceived organizational

3348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74089/psn-pdf
      July 15, 2002 - effect-race-and-sex-physicians-recommendations-cardiac-catheterization Gender, racial, and ethnic disparities in healthcare can affect patient … safety and lead to poor outcomes. … This study used actors portraying patients to explore the impact of race and sex on physicians’ decision … Analyses indicate that women and Black patients with chest pain were less likely to be referred for … day-outcomes-after-hospitalization-covid-19 https://psnet.ahrq.gov/issue/racial-and-ethnic-disparities-patient-safety

3349. SOPS Health Information Technology Patient Safety Supplemental Item Set for the Hospital Survey. | PSNet
      psnet.ahrq.gov/issue/sops-health-information-technology-patient-safety-supplemental-item-set-hospital-survey
      October 23, 2019 - Measurement Tool/Indicator SOPS Health Information Technology Patient Safety Supplemental … Citation Text: SOPS Health Information Technology Patient Safety Supplemental Item Set for the Hospital … This release of the  Health Information Technology Patient Safety Supplemental Item Set  to be used in … March 11, 2020 Health IT Patient Safety Supplemental Items for Hospitals. … March 22, 2016 AHRQ Patient Safety YouTube Channel.

3350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837149/psn-pdf
      May 18, 2022 - Human factors analysis of latent safety threats in a pediatric critical care unit. … Human factors analysis of latent safety threats in a pediatric critical care unit. … https://psnet.ahrq.gov/issue/human-factors-analysis-latent-safety-threats-pediatric-critical-care-unit … Based on direct observations, these researchers identified 226 latent safety threats affecting routine … https://psnet.ahrq.gov/issue/patient-safety-intensive-care-unit https://psnet.ahrq.gov/glossary-0#glossary-heading-term

3351. Community Pharmacy Survey on Patient Safety Culture: 2015 User Comparative Database Report, Part 1 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/pharmacy/2015-report-part-1.pdf
      January 01, 2015 - Patient Counseling (average 95 percent positive)—the extent to which patients are encouraged to talk … Patient Counseling Patients are encouraged to talk to the pharmacist; pharmacists spend enough time … Areas of Strength • Patient Counseling (average 95 percent positive)—Patients are encouraged to talk … Patient Counseling: (B2) “We encourage patients to talk to pharmacists about their medications” and … overall rating on patient safety.

3352. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions. | PSNet
      psnet.ahrq.gov/issue/formal-medicine-reconciliation-within-emergency-department-reduces-medication-error-rates
      May 01, 2019 - May 25, 2016 Association of display of patient photographs in the electronic health … record with wrong-patient order entry errors. … Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient … March 6, 2015 Improving medication safety with accurate preadmission medication lists … See More About The Topic Emergency Departments Health Care Providers Quality and Safety

3353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46154/psn-pdf
      June 07, 2017 - safety problems. … been raised that overprescribing of opioids may be an unintended consequence of efforts to improve patient … However, this Michigan study found no relationship between postoperative opioid prescribing and patient … satisfaction scores, indicating that efforts to reduce opioid prescribing may not adversely affect patient … postoperative-opioid-prescribing-and-pain-scores-hospital-consumer-assessment-healthcare https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications

3354. When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. | PSNet
      psnet.ahrq.gov/issue/when-order-sets-do-not-align-clinician-workflow-assessing-practice-patterns-electronic-health
      March 24, 2019 - March 24, 2019 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … View More Related Resources Duplicate medication order errors: safety … safety and service efficiency. … February 11, 2015 Indication-based prescribing prevents wrong-patient medication errors … January 7, 2015 Preventing potentially inappropriate medication use in hospitalized older patients

3355. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet
      psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
      January 01, 2015 - , safety, patient satisfaction, process indicators, staff engagement, and economics. … RW : During the first 7 or 8 years of the patient safety field after the Institute of Medicine report … MG : I wouldn't fault the patient safety movement for this. … RW : Anything else you wanted to talk about particularly in the realm of patient safety? … June 25, 2014 Perspective Primary Care and Patient Safety

3356. Final Progress Report: The National Quality Forum National Annual Policy Conference 2006 (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/nishimi-report.pdf
      January 01, 2024 - • Panel VI: Patient Safety and Quality. … Eisenberg Patient Safety and Quality Awards. … Innovation in Patient Safety and Quality at a Regional Level: Minnesota Alliance for Patient Safety … Innovation in Patient Safety and Quality at a Regional Level: Pennsylvania Patient Safety Authority. … Gurwitz, MD (Research); Minnesota Alliance for Patient Safety and Pennsylvania Patient Safety Authority

3357. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
      March 01, 2020 - important National Patient Safety Goal starting in 2014 and releasing a Quick Safety issue in October … Patient identification, one component of patient safety, requires that patients, caregivers, clinicians … Effectiveness of surgical safety checklists in improving patient safety. … Current issues in patient safety in surgery: a review. … Preoperative room/ operating room Out of the 200 patients in the study, 135 patients (68%) were

3358. Health IT Hazard Manager Beta-Test (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf
      May 01, 2012 - The Patient Safety Act focuses on learning from retrospective analysis of safety incidents and adverse … If patient harm cannot be ruled out, such teams typically forward the information to the patient-safety … Patient-safety teams are usually aware of the severity of patient harm resulting from a safety incident … The NPSD aggregates patient safety reports from Patient Safety Organizations, using the AHRQ Common … Health IT and Patient Safety: Building Safer Systems for Better Care.

3359. Wrong-patient orders in obstetrics. | PSNet
      psnet.ahrq.gov/issue/wrong-patient-orders-obstetrics
      September 23, 2020 - Patient misidentification errors can result in serious patient harm. … ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in obstetrics. … September 4, 2019 Critical care clinicians' experiences of patient safety during the … March 16, 2022 Maternal and neonatal health care worker well-being and patient safety … unique patient-safety challenge in obstetrics.

3360. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
      November 19, 2015 - Web page for methods and data: http://www.ahrq.gov/professionals/quality-patient- safety/pfp/index.html … /quality-patient-safety/pfp/index.html Exhibit 1. … Numerous other public and private initiatives to improve healthcare quality and patient safety were … HHS and other public and private partners are continuing to work to improve patient safety. … AHRQ’s patient safety programs continue to enable and guide improvements in health care delivery.