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4481. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. | PSNet
      psnet.ahrq.gov/issue/prospective-evaluation-consultant-surgeon-sleep-deprivation-and-outcomes-more-4000
      October 19, 2022 - This prospective study found no additional risk of complications or mortality in cardiac surgery patients … This finding contradicts the results of an earlier study in general surgery patients. … Safety in the Emergency Care Setting. … April 24, 2018 Prevalence and causes of diagnostic errors in hospitalized patients under … View More Related Resources Surgeons and systems working together to drive safety

4482. Using risk stratification to reduce medical errors in cervical cancer prevention. | PSNet
      psnet.ahrq.gov/issue/using-risk-stratification-reduce-medical-errors-cervical-cancer-prevention
      September 05, 2012 - This commentary recommends that health care systems utilize risk stratification to ensure patients are … appropriately screened and tested for cervical cancer and other diseases as a way to enhance safety … safety. … December 30, 2014 Outside case review of surgical pathology for referred patients: the … impact on patient care.

4483. Physiologic Predictors of Severe Injury: Systematic Review, Evidence Summary (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-205-predictors-trauma-care-evidence-summary.pdf
      April 01, 2018 - and Quality in conjunction with the sponsoring partner agency, the National Highway Transportation Safety … If the indicators of high-risk patients were consistent, cleaner comparisons could be made both across … Washington, DC: National Highway Traffic Safety Administration; February 2013. … Prehospital triage in the injured pediatric patient. … Decision tool for the early diagnosis of trauma patient hypovolemia.

4484. Final Progress Report: Human Factors and Systems Integration in High Technology Surgery (HF-SIgHTS) (pdf file)
      www.ahrq.gov/sites/default/files/2025-07/catchpole-report.pdf
      January 01, 2025 - Robotic Assisted Surgery (RAS) has revolutionized many procedures, with popularity amongst surgeons and patients … SCOPE Every year in the USA surgical patients experience 4000 never events, and between two and twenty … Robotic Assisted Surgery (RAS) has revolutionized many procedures, with popularity amongst surgeons and patients … safety. … positioning, incorrect patient labels (7, 46.66%) What are ways we can avoid safety hazards in robotic

4485. Accuracy of practitioner estimates of probability of diagnosis before and after testing. | PSNet
      psnet.ahrq.gov/issue/accuracy-practitioner-estimates-probability-diagnosis-and-after-testing
      May 05, 2021 - September 15, 2021 Understanding the "Swiss cheese model" and its application to patient … safety. … July 21, 2021 Failure to engage hospitalized elderly patients and their families in advance … and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients … A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.

4486. Dataform 1 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/resource/Dataform_1_Prescription_Screening_Form.pdf
      June 16, 2021 - Dataform 1 Page 1 of 4 Center of Excellence for Patient Safety Research and Practice 1/26/08 Dataform … _____ If other, specify ________________ ___ Page 2 of 4 Center of Excellence for Patient … Safety Research and Practice 1/26/08 D cription Screening Form Version 0.10 ataform 1: Pres23 … Cox 2 Inhibitors Page 3 of 4 Center of Excellence for Patient Safety Research and Practice … present Needs Chart Review: (Check box for “Yes”) Page 4 of 4 Center of Excellence for Patient

4487. The Safety and Quality of Long Term Care | PSNet
      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

4488. Using Mass Media To Spread Messages About a Quality Report | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/distribute/promote/multiple/using-media.html
      September 01, 2019 - be: Promoting a report with asthma measures through the web sites of virtual support groups for patients … Promoting a report with patient safety indicators by cultivating a blogger in your community who has … a particular concern about patient safety. … What happens when patients, family members, or others use the report to make better decisions about … Remember that this can include purchasers or policymakers as well as individual patients or families.

4489. Final Progress Report: Simulation Training For Rapid Assessment And Improved Teamwork (STRAIT) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/weinger-report.pdf
      January 01, 2024 - Key Words: Care transition, handover, teamwork, communication, patient safety, medical error, manikin … Handover quality was assessed by four indicators: the quality of verbal information about the patient … briefer than those involving stable patients. … B., Slagle, J., Kuntz, A., Speroff, T., France, D: Improving communication and patient safety in the … safety in the PACU.

4490. Improving Management of Test Results that Return After Hospital Discharge | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/improving-management-test-results-return-after-hospital-discharge
      January 01, 2023 - /Clinician Type of Care Acute Care Primary Care Health Care Theme Patient … Safety Many patients discharged from a hospital with pending test results experience medical … Outpatient providers report being unaware of up to 60 percent of results that require a change in patient … A copy of the pending tests can be printed and given to patients for outpatient appointments. … Chart reviewers rated each test result on whether it required a change in patient management and determined

4491. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49409/psn-pdf
      July 01, 2003 - This understanding is critical to the study of error and patient safety because a basic tenet of psychology … The pervasive attitude that technology is the solution to all problems can compromise patient safety … in every case driven in part by the “technological imperative”(14) is dangerous, particularly for patients … Such factors can promote the enhancement of patient safety. … Enhancing patient safety by effectively reducing the likelihood of error necessitates that actions be

4492. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
      April 01, 2025 - No. 25-0029 April 2025 AHRQ Safety Program for MRSA Prevention: Targeting SSI AHRQ Safety Program for … Apply a patient example to discover system failures. … Medical course uneventful and patient discharged home on day 5.  … Multiple factors contribute to patient outcomes. … The impact of operational failures on hospital nurses and their patients.

4493. Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. | PSNet
      psnet.ahrq.gov/issue/effectiveness-barcode-medication-administration-system-reducing-preventable-adverse-drug
      December 14, 2022 - December 21, 2022 Correlation between the number of patient-reported adverse events, … adverse drug events, and quality of life in older patients: an observational study. … February 21, 2024 Safety enhancements every hospital must consider in wake of another … for our smallest patients. … January 26, 2011 Toward learning from patient safety reporting systems.

4494. Operationalizing Patient Safety at Academic Medical Centers | PSNet
      psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
      August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. … Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. … to patient safety initiatives at AMCs. … Eisenberg patient safety and quality awards. … , solid tumor patients, and bone marrow transplant patients.

4495. Facilitator Guide: Building Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_build_ssibundle_facnotes.docx
      December 01, 2017 - your team · Learn how to proceed with improvements that do not have a strong evidence base · Locate safety … Slide 2 AHRQ Pub No. 16(18)-0004-15-EF AHRQ Safety Program for Surgery Onboarding Building Your … ask staff, how do you think the next patient will be harmed, how will the patient develop a surgical-site … Slide 10 Safety Issues & Improvement Opportunities SAY: These are the results of the Staff Safety … , and this is a SCIP measure in this patient population.

4496. A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality. | PSNet
      psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia
      May 26, 2021 - safety. … October 28, 2020 Effects of nurse-to-patient ratio legislation on nurse staffing and … Related Resources Facilitators and barriers to the implementation of surgical safety … November 15, 2023 Patient safety of perioperative medication through the lens of digital … pain in opioid-naive patients undergoing elective surgery in a large American health system.

4497. Conclusions | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/cauti-interim/cauti-interim5.html
      July 01, 2013 - national project team is committed to the overall project goals of reducing CAUTI and enhancing the safety … Although CAUTIs are typically identified following admission to an in-patient setting, more than half … of all hospitalized patients are admitted through the ED. … Furthermore, data collection related to the assessment of safety culture is ongoing. … Safety Culture (HSOPS) and the Team Checkup Tool.

4498. Communicating With Patients and Families About Antibiotic Decisions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/communicating-decisions-one-pager.pdf
      September 01, 2022 - Patients and Families About Antibiotic Decisions Patients want to feel HEARD1-3 • Say: “What … ” • Sit at eye level with the patient. … Look at the patient frequently in between typing. … AHRQ Safety Program for Improving Antibiotic Stewardship – Ambulatory Care References 1. … What patients want. Patient Educ Couns. 2013 Mar;90(3):287- 90. PMID: 23395286. 2.

4499. Measuring the Value of Remote ICU Monitoring (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r01hs015234-thomas-final-report-2008.pdf
      January 01, 2008 - Results: While Safety Climate scores within the monitored ICUs improved, the overall SCS scores for … Workflow, Task Analysis, Interruption, Time-and-Motion Study, ICU Remote Monitoring, Telemedicine, safety … Average daily costs, costs per case, and costs per patient were computed. … The impact of a tele-ICU on provider attitudes about teamwork and safety climate. … Third revision submitted to Quality and Safety in Healthcare 12/08.

4500. Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. | PSNet
      psnet.ahrq.gov/issue/why-do-hospital-prescribers-continue-antibiotics-when-it-safe-stop-results-choice-experiment
      October 28, 2020 - discontinuation would conflict with local guidelines, when systems clearly indicated antibiotics, and when patients … safety? … May 4, 2022 A qualitative study of what care workers do to provide patient safety at … safety. … October 21, 2020 Clinical deterioration and hospital‐acquired complications in adult patients