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6501. Not a Miscarriage | PSNet
      psnet.ahrq.gov/web-mm/not-miscarriage
      June 01, 2005 - of her bicornuate uterus, several important safety nets also failed. … Pre-anesthesia checklists to improve patient safety. … Making health care safer: a critical analysis of patient safety practices. … Agreement September 24, 2024 Predictors of likelihood of speaking up about safety … Related Resources Annual Perspective Improving Diagnostic Safety

6502. The Effectiveness of an HIT-based Care Transition Information Transfer System to Improve Outpatient Post-Hospital Care for Medically Complex Patients - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017864-ciemins-final-report-2012.pdf
      January 01, 2012 - safety, and efficient use of health care services. 4. … and family; and patient health status may be at a new level, posing challenges to patients, families … While the interview process included patients collecting their medications, it also relied on patient … Project activities included patient “teach 13 back” (having patients repeat discharge instructions … safety and continuity of care.

6503. Disposition of Comments for CER 178 Newer Medications for Lower Urinary Tract Symptoms (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/prostatic-hyperplasia-medications_disposition-comments.pdf
      May 26, 2016 - This leads to a large variable practice which introduces expense, unnecessary patient risk and prolonged … that it synthesizes new medications and aids clinicians seeks evidence-based review on appropriate patient … These might be meaningful to patients and providers, too. … of study limitations and imprecision in measurement, it remains unclear if an appreciable number of patient … with OAB--and explicitly note (applicability) that there are little data on the effectiveness and safety

6504. CDS Standards and Regulatory Frameworks Workgroup: An Initial Taxonomy of Override Reasons for PC CDS Recommendations (pdf file)
      cdsic.ahrq.gov/sites/default/files/2024-07/SRF_Taxonomy%20of%20PC%20CDS%20Override%20Recommendations_508_0.pdf
      January 01, 2024 - Journal of Patient Safety. 2022;18(6):630-6. doi:10.1097/pts.0000000000001034. … Drug Safety. 2017 Nov;41(3):297-302. doi:10.1007/s40264-017-0615-1. … BMJ Quality & Safety. 2018;27(9):718-724. … Journal of Patient Safety. 2022;18(6):630-6. doi:10.1097/pts.0000000000001034. 30 Wong A, Seger DL, … Drug Safety. 2017 Nov;41(3):297-302. doi:10.1007/s40264-017-0615- 1.

6505. CDS Standards and Regulatory Frameworks Workgroup: An Initial Taxonomy of Override Reasons for PC CDS Recommendations (pdf file)
      digital.ahrq.gov/sites/default/files/SRF_Taxonomy%20of%20PC%20CDS%20Override%20Recommendations_508_0.pdf
      July 01, 2024 - Journal of Patient Safety. 2022;18(6):630-6. doi:10.1097/pts.0000000000001034. … Drug Safety. 2017 Nov;41(3):297-302. doi:10.1007/s40264-017-0615-1. … BMJ Quality & Safety. 2018;27(9):718-724. … Journal of Patient Safety. 2022;18(6):630-6. doi:10.1097/pts.0000000000001034. 30 Wong A, Seger DL, … Drug Safety. 2017 Nov;41(3):297-302. doi:10.1007/s40264-017-0615- 1.

6506. Team-Based Primary Care: Convergence of Improving Engagement, Safety, and Enhanced Joy in Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teambased-1.pdf
      May 02, 2016 - All of these factors led to improved patient and provider engagement as well as improved patient safety … ■ Lack of patient engagement affects patient outcomes: Engaging patients in their care is the cornerstone … , leading to improved health outcomes and patient safety … medical home transformation.8 ■ Improved patient safety: According to one team- based care leader … safety.

6507. Practice and Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-improvement.html
      May 01, 2024 - Practice Improvements To Improve Patient Safety Three grants focus on practice improvement efforts to … improve patient safety. … Patient Safety section of this report. … ExPERTS-PC: Engaging Patients in Event ReporTing for Safety in Primary Care (K08) PI: Anjana Estelle … team related causes of ADEs from the reports of a multistate Patient Safety Organization.

6508. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
      June 11, 2003 - If needed, changes in policy or procedure are made to improve patient safety. … Ongoing training is provided to all staff on patient safety programs and requirements. … Advances in Patient Safety: Vol. 4 80 References 1. … Patient safety: achieving a new standard for care. … Patient safety: instilling hospitals with a culture of continuous improvement.

6509. Final Progress Report: Improving Medication Management Practices and Care Transitions Through Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/feldman-report.pdf
      January 01, 2024 - safety have identified poor medication management as one of the greatest contributors to adverse patient … of data on patients’ clinical and functional statuses as well as on patient demographics, living arrangements … For Patient Survey Sample As mentioned above, a subsample of patients was interviewed 60 days after home … Patient Survey Sample Findings Supplemental information collected from a subsample of patients is reported … Only 10% of the patients’ records indicated that the nurse advised the patient to discuss medication

6510. 025-Assessing-Evc-Webinar-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/025-assessing-evc-webinar-notes.docx
      October 01, 2024 - Decolonizing patients 2. Decontaminating the healthcare environment 3. … safety goals in a respectful and inclusive manner. … safety personnel, and other Comprehensive Unit-based Safety Program (CUSP) team members. … Slide 19 Step 3: Clean Patient Rooms SAY: The EVC associate then cleans the patient rooms during their … It is important to work together to protect patients from preventable pathogens such as MRSA and remember

6511. Implementation Guide: Prediabetes and Type 2 Diabetes: Part One, Screening (pdf file)
      cds.ahrq.gov/sites/default/files/cds/artifact/1061/2024_CDS_Connect_IG_Diabetes_Part_One_Screening_0.pdf
      January 01, 2024 - The artifact provides the opportunity to present information to at- risk patients through a patient-facing … Patient-Facing CDS Development Considerations Patients and their caregivers are increasingly seeking … In turn, the successful implementation of patient-facing CDS helps support quality and safety, resulting … A USPSTF SME validated that excluding pregnant patients was appropriate. … ” Patients with a recorded race of “African American.”

6512. Assessing the Relationship between Care Processes and Clinical Decision Support for Order Entry – Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r03hs0S26266-zhang-final-report-2022.pdf
      January 01, 2022 - Patient inclusion figure Patients who had inpatient visits in 2018 and 2019 (N=188802) Exclude … We controlled for patients’ age, a binary indicator of whether the patient is English speaking, sex … Future studies may use other acute disease burden indicators such as Laboratory-based Acute Physiology … Effects of computerized physician order entry and clinical decision support systems on medication safety … care" protocols into clinicians' workflow via care provider order entry: impact on quality-of-care indicators

6513. Assessing the Health and Welfare of the HCBS Population | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab3b.html
      December 01, 2012 - Population Introduction HCBS Population Availability and Use of State Medicaid HCBS Outcome Indicators

6514. Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/Telediagnosis-brief2.pdf
      August 03, 2020 - Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis PATIENT SAFETY … Similar to in-person interactions, the clinician-patient relationship and the level of patient involvement … Despite its importance to diagnostic safety, little attention has been paid to the impact of patient … engagement and patient participation in telediagnosis,17,18 beyond patient satisfaction. … Diagnostic Safety • Safety may be enhanced by improved access, a better sense of the patient’s home environment

6515. Diffusion of Responsibility Leads to Danger | PSNet
      psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
      November 08, 2013 - When high acuity and patient volume requires that admitted patients be held in the ED for prolonged periods … The long road to patient safety: a status report on the patient safety systems. … safety climate. … design guarantee patient safety? … safety culture in hospital setting: a systematic review.

6516. Protocol for Identifying and Treating Children With Sepsis Syndrome in the Emergency Department (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-228-fullreport.pdf
      February 01, 2018 - because it leads to more meticulous patient assessment (Larsen, et al., 2011). … Measure Topic – patient safety: No. k. Measure Topic – family experience with care: No. l. … Enable a user to electronically select, sort, retrieve, and output a list of patients and patients' … can be alerted that the patient is eligible for the sepsis protocol. … New York State Department of Health – Office of the Medical Director Office of Quality and Patient Safety

6517. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
      June 30, 2004 - Main Abstract Objective: The Applied Strategies for Improving Patient Safety (ASIPS) collaborative … ‡ Fixed choice (Yes/No) + optional brief narrative Number of patients involved Fixed choice (1 or more … Safety compendium.18 Advances in Patient Safety: Vol. 2 142 Figure 1. … safety reporting system to inform the development of patient safety interventions. 1. … Advances in Patient Safety: Vol. 2 144 2.

6518. Picking Up the Cause of the Stroke | PSNet
      psnet.ahrq.gov/web-mm/picking-cause-stroke
      August 07, 2024 - The physicians caring for the patient assumed the PICC was safe to use, and the patient began receiving … How best to use PICCs is an important clinical and safety question. … Safety Enhancement Program and Center for Clinical Management Research of the VA Ann Arbor Health System … J Patient Saf. 2015 Nov 10; [Epub ahead of print]. [go to PubMed] 4. … Do clinicians know which of their patients have central venous catheters?

6519. Layout 1 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/atypical-antipsychotics-off-label-update_executive.pdf
      September 01, 2011 - Comparative Effectiveness of Off-label Use of Atypical Antipsychotics reviewed the scientific evidence on the safety … potentially fatal blood disorder of bone marrow suppression, and it requires frequent blood tests for safety … Most trials used flexible dosing, resulting in patients taking a wide range of doses. … future research, standardized measures of disease severity might allow for greater knowledge of the patient … Trials assessing the newer agents’ efficacy and safety are necessary if they are to be used off-label

6520. Final Progress Report: Yale Center for Healthcare Innovation, Redesign, and Learning (CHIRAL) (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/chaudhry-report.pdf
      January 01, 2025 - IHI/NPSF Patient Safety Congress, 2018 May, Boston MA. 11. … of interventions to improve patient safety during intra-hospital transitions. … The Joint Commission Journal on Quality and Patient Safety. 2017;43(11):565-72. 4. … Journal of Patient Safety. 2019 Sep;15(3):198-204.6. 6. … IHI/NPSF Patient Safety Congress; 2018; Boston, MA. 7. Minges, Karl.