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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/solberg.html
April 01, 2015 - Transformational Elements
Accessible Services
Coordinated Care
Health Information Technology
Patient-Centered … Care
Quality & Safety
Overview of Transformation Efforts
In 2010 the Minnesota Department … standards focused on five key areas:
Continuous access and communication between the HCH and the patient … Care coordination for improved patient-and family-centered care. … Continuous improvement in patient experience, health outcomes, and cost effectiveness.
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - The
Brigham and Women’s Hospital’s (BWH) Patient Safety Collaborative, which included Ambulatory Patient … a colonoscopy following safety net team outreach to the patient and (2) the
proportion of patients … 56.9% when accounting for the proportion of patients who were effectively caught by the safety net by … outreach via a clinic-determined method (hard copy letters, phone calls to client, or outreach
to patient … Identify drivers of change to ensure patient safety and to minimize patient harm.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
May 01, 2011 - Team Lead(s): Representative(s) from Patient Safety and/or Risk Management, who are also connected to … Understanding patient safety. McGraw Hill Medical, 2012. … Ensure patient safety/risk management representatives are known to staff and available. … Advocate for patient safety initiatives.
Dropping out
Transferring to a different unit.
Quits. … Understanding patient safety. McGraw Hill Medical, 2012.
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily1.html
July 01, 2018 - patient safety and quality in the hospital setting. … Because the Guide is intended to facilitate patient and family engagement in health care safety and … The conceptual framework highlights (1) the ultimate goals of improving quality and patient safety through … Ultimately, engaging patients and families in patient safety and quality will likely lead to anticipated … safety, patient and staff satisfaction, and health outcomes.
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psnet.ahrq.gov/issue/association-dose-tapering-overdose-or-mental-health-crisis-among-patients-prescribed-long
July 13, 2022 - Study
Association of dose tapering with overdose or mental health crisis among patients … Sudden discontinuation of opioids has been linked to increased patient harm. … diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient … August 10, 2022
Association of patient and family reports of hospital safety climate … Related Resources
Evaluation of policies limiting opioid exposure on opioid prescribing and patient
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www.ahrq.gov/ncepcr/reports/2025-annual-report/overview.html
August 01, 2025 - . $17.2 million from the Patient Safety appropriation. $14.9 million from the Patient-Centered Outcomes … Safety (n=18, 17%), followed by Practice and Quality Improvement (n=17, 16%), Healthcare Systems and … Patient safety was added as a new main topic area for this report, making comparisons with the previous … , people with limited English proficiency, low income or medically underserved patients, Medicare and … Safety 4 medRxiv 4 Our previous report found a greater number of publications (516 from 82 grants) for
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cds.ahrq.gov/sites/default/files/cds/artifact/1056/2024_CDS_Connect_IG_Statin_CVD_Patient_Facing_2.pdf
January 01, 2024 - artifact provides the opportunity to present information to at-risk
patients through a patient-facing … In turn, the successful
implementation of patient-facing CDS helps support quality and safety—positively … safety. … safety reasons. … safety reasons.
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cds.ahrq.gov/sites/default/files/cds/artifact/1056/2023_CDS_Connect_IG_Statin_CVD_Patient_Facing.pdf
January 01, 2023 - to present information to at-risk
patients through a patient-facing health IT system (e.g., a patient … In turn, the successful
implementation of patient-facing CDS helps support quality and safety—positively … safety. … safety reasons. … safety reasons.
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
May 01, 2017 - no surprise that communication challenges can harm patients. … One example used by many facilities is the AHRQ Survey on Patient Safety culture. … The Doctors Company: Patient Safety/Risk Management Strategies. An Ounce of Prevention . 2015. … Through these measures, briefings can help improve patient safety. … Development and validation of the SURgical Patient Safety System (SURPASS) checklist.
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - opioids on sedation and respiratory depression, differences between
opioid-naïve and opioid-tolerant patients … To help them prevent errors, patients and families should be
empowered to detect medication errors by … ISMP Medication Safety Alert! Community/Ambulatory Care Edition. … Pa Patient Saf Advis. 2013;10:27-33. [Available at]
8. ISMP Medication Safety Alert! … of patient input n quality improvement and safety initiatives
Quality processes and risk
management
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement.pptx
May 01, 2017 - care, patient care delivery, and outcomes
Who should shadow? … Staff of patient care units where
culture scores indicate a poor
score in teamwork and safety
Units with … AHRQ Safety Program for Perinatal Care
13
Teamwork & Comm.
13
STEP2
Status of the patient
Team members … breach that hinders patient well-being
AHRQ Safety Program for Perinatal Care
19
Teamwork & Comm. … Joint Commission Journal of Quality and Patient Safety. 2007 Jan;33(1):34-47. PMID: 17283940.
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digital.ahrq.gov/ahrq-funded-projects/implementing-low-literacy-multimedia-information-technology-system-enhance/annual-summary/2012
January 01, 2012 - Implementing a Low-Literacy, Multimedia Information Technology System to Enhance Patient-Centered Cancer … Organization
Northwestern University
Funding Mechanism
RFA: HS07-007: Ambulatory Safety … Due to challenges with patient recruitment, Ms. … Patient feedback was largely positive and was used to improve the software. … Colorectal, Low Literacy, Low SES/Low Income*, Medically Underserved, Racial or Ethnic Minorities*, Safety
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psnet.ahrq.gov/node/33854/psn-pdf
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
March 1, 2018
Ball JE, Griffiths P. … Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. … https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
Perspective
Errors … in hospitals remain a major cause of death.(1) Many patient safety initiatives focus on reducing the … safety grades
reported by nurses.(4) Where missed care rates are higher, patients are less likely to
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www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
January 01, 2024 - Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE)
Advancing Patient … Key Words: quality measures, immunomodulating drugs, patient safety
2
Advancing Patient Safety Innovation … safety
errors and to allow providers to benchmark their performance on specific patient safety issues … patient safety continue to focus on hospitalized patients. … We included 926 patients from a university and 132 patients from a safety
net health system.
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digital.ahrq.gov/sites/default/files/docs/citation/modeling-pcmh-principles-attributes-patient-experiences-technical-report.pdf
November 01, 2014 - Although the patient scenarios may be of interest primarily to patients and clinicians, health
IT vendors … • Coordinated care
• Superb access to care
• A systems-based approach to quality and safety … The PCMH
might offer a patient portal to provide this functionality, and could offer patients interoperability … A patient portal extends a practice Web site to provide a secure location that
patients can use to receive … A portal can also allow patients to access their personal health information.
Patient Education.
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Barnes, MD, FACEP and Garth Utter, MD, MSc, FACS
Background
This case illustrates the patient safety … Alternatively, patients should be instructed to return
to the index ED for re-evaluation. … Take-Home Points
Evaluate all patients for their risk of wound infection and poor wound healing. … Barnes, MD, FACEP
Consulting Editor, AHRQ’s Patient Safety Network (PSNet)
Health Sciences Clinical … Safety Network (PSNet)
Professor
Department of Surgery, Division of Trauma
UC Davis Health
ghutter
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-user-guide.pdf
July 01, 2018 - Community Pharmacy Survey on Patient Safety Culture: User's Guide
PHARMACY
SURVEY
ON PATIENT
SAFETY … status of patient safety culture,
Identify strengths and areas for patient safety culture improvement … Safety Culture Composites
The Community Pharmacy Survey on Patient Safety Culture emphasizes patient … Patient Safety Culture Composites and Definitions
Patient Safety Culture Composite Definition: The extent … mistakes
Patient Counseling Patients are encouraged to talk to the pharmacist;
pharmacists spend
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-iv-patient-safety-practices-year-2.pdf
May 01, 2025 - Director, General Patient Safety Program
Center for Quality Improvement and Patient
Safety
Agency … Patients for Patient Safety, U.S. … safety practices for responding to harms experienced by patients during
clinical care (N=8) ....... … safety outcomes
• Programs for responding to harms experienced by patients during clinical care … safety practices for responding to harms experienced by patients during
clinical care (N=8)
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www.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
June 01, 2018 - However, too often, the quality of care provided to patients is substandard. … Yet, in a sample of Medicare patients in New Jersey, only 21 percent of eligible patients received beta … In 1992, half of all patients diagnosed with a cold and two-thirds of patients diagnosed with acute bronchitis … As a result, these patients spent more time in the hospital and health care costs increased. … , available resources, patient preferences, or even clinical uncertainty.
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digital.ahrq.gov/sites/default/files/docs/page/the-personal-health-partner-using-health-information-technology-to-promote-better-pediatric-primary-care.pdf
June 16, 2021 - The Personal Health Partner
1
AHRQ Health Information Technology
Ambulatory Safety and Quality | PCC … for patients. … Telephony also accommodates low-liter-
acy patients by directing the conversation and provid-
ing a clear … potential
content for primary care is greater than anyone would
have time for,” and suggests engaging the patient … exposure to secondhand smoke and counseling a
parent to make a quit plan, could occur outside of
patient