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4541. Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review. | PSNet
      psnet.ahrq.gov/issue/impact-computerised-physician-order-entry-cpoe-incidence-chemotherapy-related-medication
      May 25, 2022 - reduction in chemotherapy-related medication errors, indicating that CPOE is a valuable strategy for this patient … March 24, 2021 Use of patient complaints to identify diagnosis-related safety concerns … factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients … June 15, 2022 View More Related Resources Patient safety threats … safety with antineoplastics?

4542. Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective observational study. | PSNet
      psnet.ahrq.gov/issue/analysis-pharmacist-identified-medication-related-problems-two-united-kingdom-hospitals
      July 31, 2019 - This prospective cohort study of 1,503 patients sought to identify timepoints during the inpatient hospitalization … April 7, 2021 Use of patient complaints to identify diagnosis-related safety concerns … Interdisciplinary collaboration across secondary and primary care to improve medication safety … August 26, 2020 Oncology pharmacist-led medication reconciliation among cancer patients … 4, 2010 View More See More About The Topic Hospitals Quality and Safety

4543. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. | PSNet
      psnet.ahrq.gov/issue/clarifying-adverse-drug-events-clinicians-guide-terminology-documentation-and-reporting
      February 03, 2011 - February 3, 2011 Developing indicators of inpatient adverse drug events through nonlinear … December 23, 2011 Vital signs: improving antibiotic use among hospitalized patients. … Annual Perspective Annual Perspective: Topics in Medication Safety

4544. Incidence and types of preventable adverse events in elderly patients: population based review of medical records. | PSNet
      psnet.ahrq.gov/issue/incidence-and-types-preventable-adverse-events-elderly-patients-population-based-review
      June 23, 2015 - Results indicated a significant number of adverse events in both elderly (>65) and nonelderly patient … events , and events related to procedures; these findings suggest potential areas for safety interventions … February 17, 2011 The nature of adverse events in hospitalized patients. … February 10, 2011 Work system design for patient safety: the SEIPS model. … Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety

4545. Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study. | PSNet
      psnet.ahrq.gov/issue/community-pharmacy-medication-review-death-and-re-admission-after-hospital-discharge
      July 08, 2008 - February 4, 2010 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … Resources A multi-method exploratory evaluation of a service designed to improve medication safety … enhancing collaboration between community pharmacists and primary care providers to improve medication safety … February 22, 2023 Understanding factors that could influence patient acceptability of … October 31, 2017 In-home medication reviews: a novel approach to improving patient care

4546. Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy. | PSNet
      psnet.ahrq.gov/issue/challenging-authority-during-life-threatening-crisis-effect-operating-theatre-hierarchy
      December 02, 2015 - study, the majority of anesthesia trainees complied with a supervisor's order to transfuse blood to a patient … September 1, 2021 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … June 16, 2011 The relationship of the emotional climate of work and threat to patient … March 2, 2011 Changes in safety attitude and relationship to decreased postoperative … morbidity and mortality following implementation of a checklist-based surgical safety intervention.

4547. In Conversation with…Barbara A. Blakeney, MS, RN | PSNet
      psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
      August 01, 2005 - It is a continuing puzzle that health care does not respond to economic and research indicators the same … So when Linda Aiken talks about it [ nursing's patient safety agenda being unfinished ], I agree with … A strong evidence base suggests that focusing on nursing would improve patient safety. … June 16, 2011 Working conditions that support patient safety. … June 9, 2011 Nursing 2006 Patient-safety survey report.

4548. Archived: Final Evidence Summary: Dental Caries in Preschool Children: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary19/dental-caries-in-preschool-children-screening-2004
      April 15, 2004 - Two patient-based assessments of management of fluoride supplementation have been reported. 25 , 26 … of these indicators. … d Approximate percentage of patients with fluoridated water. … Does newly acquired knowledge improve patient care? JAMA 1980;244:2183-5. … A review of their clinical use, cariostatic mechanism, efficacy and safety.

4549. Appendix D: Four Suggested Key Areas | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/delivery-initiative/casalino/paper/idkeydsrapd.html
      February 01, 2014 - Accounting for variation in technical quality and patient satisfaction: the contribution of patient, … Comparison of change in quality of care between safety-net and non-safety-net hospitals. … on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators … Avoiding of high-risk patients by provider organizations Werner RM, Asch DA, Polsky D. … Exclusion of patients from pay-for-performance targets by English physicians.

4550. Building Your SSI Prevention Bundle: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/build-ssi-bundle-fac-notes.html
      December 01, 2017 - Understand how to use the results of your staff safety assessment to build a bundle.  … Locate safety program for surgery resources on the project Web site. … staff, how do you think the next patient will be harmed, how will the patient develop a surgical-site … Slide 11: Safety Issues & Improvement Opportunities Say: These are the results of the Staff Safety … , and this is a SCIP measure in this patient population.

4551. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/867461
      January 31, 2024 - Patient Safety in Frail Older Patients November 26, 2019 This piece describes patient safety risks when … https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients https://psnet.ahrq.gov/issue/ … Patients provide a unique insight on patient safety. … Patients provide a unique insight on patient safety. … Patient Safety in Frail Older Patients November 26, 2019 This piece describes patient safety risks when

4552. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/references.html
      May 01, 2023 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families References … A 10-year journey engaging patients in patient safety education, research, and improvement [abstract] … Quality indicators for patient safety in primary care. … National Agenda for Action: Patients and Families in Patient Safety. 2008. … Identification of an updated set of prescribing—safety indicators for GPs.

4553. CDC guideline for opioid prescribing associated with reduced dispensing to certain patients with chronic pain. | PSNet
      psnet.ahrq.gov/issue/cdc-guideline-opioid-prescribing-associated-reduced-dispensing-certain-patients-chronic-pain
      October 13, 2018 - Misuse of prescription opioids represents a serious patient safety issue. … authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered … November 16, 2022 Results of an effort to integrate quality and safety into medical and … February 23, 2022 The abrupt expansion of ambulatory telemedicine: implications for patient … safety.

4554. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable | PSNet
      psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
      December 20, 2023 - stress for all parties involved . 9 This patient’s case highlights a patient safety issue that can … plays a vital role in patient safety by decreasing risk for errors during transitions of care. … In this patient’s case, a patient safety event was avoided due to the inpatient discharge medication … Systems Change Needed Patient safety is an inherent responsibility of the clinical microsystem. … Improving patient safety within clinical microsystems begins with raising the work unit’s understanding

4555. PS Grantee | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/index.html?page=4
      January 01, 2024 - of General Patient Safety has funded research grants on a variety of patient safety topics since 2000 … These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: P30 HS 023506 Topic(s): Human Factors Approaches To Improve Patient Safety, Patient Safety … Safety Publication Date: September 2019 Making Acute Care More Patient Centered, Patient Safety … Safety, Patient and Family Engagement, Patient Safety Learning Laboratory Publication Date: September

4556. SureScripts - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/SureScripts%20Final%20Report.pdf
      January 11, 2007 - safety outcomes and to quantify the extent to which the gains with respect to medication- related patient … in the following conceptual domains: patient safety, effectiveness of patient care, efficiency of patient … Recommendations for improvement of efficiencies and patient safety were numerous and are listed below … Patient safety gains: E-prescribing theoretically can improve patient safety in at least the following … Drug alerting at point of prescribing has the potential to improve patient safety in the outpatient

4557. Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
      January 22, 2008 - safety and successful patient care.6 Incomplete information transfer and incomplete and/or unclear … safety. … Transitions in care: Studying safety in emergency department signovers. … Patient safety practices related to patient safety goal 2E. … British Medical Association, National Patient Safety Agency, NHS Modernisation Agency, Safe Handover

4558. Statistical Brief #11
      hcup-us.ahrq.gov/reports/statbriefs/sb11.jsp
      June 11, 2008 - Variables for Revisit Analyses American Hospital Association (AHA) Linkage Files AHRQ Quality Indicators … safety and cost concerns. … the rise.* The increase in elective C-sections has sparked recent attention, given mother and infant safety … A recent NIH State-of-the-Science conference addressed safety and quality concerns regarding Cesarean … DRGs comprise a patient classification system that categorizes patients into groups that are clinically

4559. Safe Medication Administration: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
      July 01, 2023 - use. 4,5 , 6,7 Use of a uniform mixed preparation unitwide for all patients to reduce variability … Slide 10: Key Safety Elements: Create Independent Checks Assessing appropriateness of patient … Slide 16: Key Safety Elements: Patient and Family Engagement Discuss risks and benefits of oxytocin … Improving patient safety and uniformity of care by a standardized regimen for the use of oxytocin. … Obstetrical accidents involving intravenous magnesium sulfate: recommendations to promote patient safety

4560. Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use | PSNet
      psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
      September 13, 2023 - Innovation Patient Safety Focus This innovation is designed to reduce potentially inappropriate prescribing … Based on the client's medication list and clinical indicators, the software identifies five types of … January 18, 2023 Patient Safety Innovations Pharmacist-led … July 21, 2021 Patient Safety Innovations Project BOOST … Patient Safety Innovations Hospital at Home℠ Care Reduces Costs, Readmissions