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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - Barnes, MD
This case highlights several related patient safety issues that can arise when a patient … 1) the harmful effects of hospital and ED crowding on patient safety, 2) the necessity for a safe and … Background
Hospital crowding is emerging as an important theme in relation to patient safety. … Officially termed Ambulance Patient Offload Time (APOT) by the California Health and Safety Code, wall … safety, patient experience, and the morale of hospital staff.
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www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary/skin-cancer-screening
April 18, 2023 - Studies of patient skin self-examination were excluded because this topic is covered in the 2018 USPSTF … Overdiagnosis can result in overtreatment that may not benefit the patient. 14
Data Extraction and … Studies used large databases with patient information from the US (SEER [Surveillance, Epidemiology, … Effects of the German skin cancer screening programme on melanoma incidence and indicators of disease … questions (KQs) that the review will address to allow the USPSTF to evaluate the effectiveness and safety
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - safety concern as patients move across various levels of care and care settings. … comorbidities, patients with long diabetes duration, or patients with a prior history of hypoglycemia … safety during hospital admission. 15
Additionally, there may be challenges related to providers accessing … safety through medication reconciliation. … Cases
Duplicate Insulin Order
March 1, 2019
Addressing safety
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - safety issue. … does not appear to offer any evidence-based patient safety measures proven to prevent
harm by decreasing … The safety implications of missed test results for hospitalised
patients: a systematic review. … CLIA program and HIPAA privacy rule; patients' access to
test reports. … Engage patients in following up on pending tests
2.
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psnet.ahrq.gov/web-mm/dissecting-presentation
May 05, 2021 - and up to 70% in high-risk groups.( 2,4 ) As with the patient in this case, patients with AAD do not … While the absence of chest pain in this patient may seem unusual, it is not—fully one-third of patients … In this patient, a right hilar fullness was noted. … in older patients. … Safety
July 1, 2018
WebM&M Cases
Missing ECG
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/osteoporosis-bone-fracture_executive.pdf
March 01, 2012 - Process
In 1979, the FDA published its first Guidance Document
for the clinical evaluation of the safety … Patient inclusion criteria for FDA
clinical trials consisted of objective evidence of disease
(i.e. … (Cramer, 2008) Adherence (or
compliance) is defined as “the extent to which a patient acts in
accordance … In March 2010, the
FDA issued a followup to its 2007 safety review,
noting the inconsistency in the … And what patient factors are important
(such as the aforementioned low BMD at baseline)
in terms of
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www.ahrq.gov/hai/cusp/toolkit/content-calls/zero-clabsi.html
April 01, 2013 - And emphasis now at this particular patient safety issue is reported by all hospitals in all units across … Improving our patient safety work was related to three things. … As we go forward, we see challenges in keeping CLABSI reduction in patient safety on the unit’s radar … safety journeys not only for central lines but for other patient harm. … It really is a foundation on which units can build their patient safety process.
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018275-parsons-final-report-2013.pdf
January 01, 2013 - across all providers who rendered health services to the patient. … Total
volume of health care services and costs per patient were stratified into yearly time periods … tasks
(e.g., typing, printing) and expectations about EHRs (e.g., the EHR will improve medication
safety … Patient goal
Antithrombotic
therapy
Patients 18+ with ischemic vascular disease
(IVD) or 40+ with … Patient-Centered Medical
Home and Quality Measurement in Small Practices.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/guidance-cg-cahps.pdf
April 01, 2021 - Learn
more about these item sets:
• Patient Narratives
• Patient-Centered Medical Home
• Health Literacy … Similarly, it is
not required that the patient have the same insurance coverage the patient had
at … To ensure that results are comparable, do not target specific patient populations, such
as patients … Survey results are typically reported along with other measures of
quality and safety. … In 3.0 and 3.1,
patients rate the
provider. In 4.0,
patients rate the
visit.
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effectivehealthcare.ahrq.gov/sites/default/files/adhd_disposition-comments.pdf
October 01, 2011 - The document is
“intended to help health care decision makers—patients and clinicians,
health system … From this, we can
then identify gaps in service and develop
responses which will help patients and … their
families in the shorter term and allow patients to
meet their potential in all areas of their … data) and DEA sales data from industry sources in ARCOS
database which are not patient-level data … p.149, non-white and low income youth
mentioned in discussion of patient preferences
Peer Reviewer
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - enhance patient safety by mitigating drug discrepancies across the continuum of care. … Recommendations for Medication Management Resources to improve prescribing safety in older patients … The top patient safety strategies that can be encouraged for adoption now. … Discrepancies between in-home interviews and electronic medical records on regularly used drugs among home care clients … Geriatrics
Medication Safety
View More
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs025654-lenert_final-report-2023.pdf.pdf
January 01, 2023 - department settings with evidence of injuries, choose not to disclose abuse
because of privacy and safety … patient privacy while screening for a confidential condition is difficult. … This figure shows the patient questionnaire administered in kiosk mode. … The non-interruptive reminder for medical assistants to screen patients
remains active until a patient … patient management forms.
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Patient counseling strategies are an important part
of limiting discrepancies and may empower the patient … understand the information provided is
https://psnet.ahrq.gov/issue/duplicate-medication-order-errors-safety-gaps-and-recommendations-improvement … Patient counseling, including teach-back, written directions for the patient, and smartphone medication … https://psnet.ahrq.gov//#5
https://www.ahrq.gov/patient-safety/reports/engage/interventions/teachback.html … psnet.ahrq.gov//#8
https://psnet.ahrq.gov//#8
https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/npsd-spotlight_behavioral-health.pdf
September 01, 2025 - events submitted by Patient
Safety Organizations (PSOs). … Safety Databases (NPSD) as authorized by
the Patient Safety and Quality Improvement Act of 2005 (PSQIA … 69.0%
Near Miss: a patient safety event that did not reach the
patient. 2,187 13.1%
393 14.3% … and staff harm, patient
safety culture, and workplace safety. … and Event Characteristics
Patient Sex
Patient Age Group
Extent of Residual Harm to Patients
Report
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-145-fullreport.pdf
July 01, 2016 - The workgroup developed a set of
safety thresholds based on utilization data and published literature … Measure Topic – patient safety: Yes.
k. Measure Topic – family experience with care: No.
l. … and
parent counseling about health, nutrition, safety, parenting, and psychosocial issues. … Safety information for stimulant medications approved for ADHD treatment by
the U.S. … Treatment of attention deficit hyperactivity disorder in
children and adolescents: safety considerations
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Innovation Patient Safety Focus
The SASH program personalized care coordination services successfully … and stakeholders to identify ways that providers of affordable housing could support the
health and safety … Older Americans 2010: Key indicators of Well-
Being. December 2010.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/health-literacy-transcript.html
December 01, 2017 - and Safety Quality. … If we look also at the area of patient safety; all of you on your units are aware of the issue of sentinel … care for patients that do have catheters, help improve their patient safety by reducing infection risks … So for example, care plans for patient safety will often include plans to try to prevent falls. … There are sometimes care plans for patient safety, so they can be doing in terms of reducing risk of
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/health-literacy-pfe-transcript.doc
July 09, 2013 - and Safety Quality. … If we look also at the area of patient safety; all of you on your units are aware of the issue of sentinel … care for patients that do have catheters, help improve their patient safety by reducing infection risks … So for example, care plans for patient safety will often include plans to try to prevent falls. … There are sometimes care plans for patient safety, so they can be doing in terms of reducing risk of
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017189-trivedi-final-report-2010.pdf
January 01, 2010 - On this screen, the application also provides safety-related reminders and documentation. … EHR major modules
Central Infrastructure
Reference tables and controls
Security
Relationships
Client … demographics
Provider demographics
Organization demographics
Client Chart
Intake
Screening/Assessment … access
Payor access
Client proxy access
Department of Children’s Services
CENTERSTONE EHR MAJOR … a new prescribing interface to support use of the algorithm, to include collection
of key clinical indicators
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/glaucoma-treatment_disposition-comments.pdf
April 01, 2012 - AAO-AGS
Executive
Summary
This AHQR document attempts to achieve a worthy goal: to
evaluate the safety … Only the most advanced,
nearly endstage, glaucoma patients reach that level, and to allow
a patient … Peer Reviewer
#4
Results Patient utilities have also been found to be diminished for patients
with … study
outcomes that are reported by the patient, and are perceived by
the patient to be important. … of IOP and how treatment
should be modified for those cases 'resistant' to change--that is,
what indicators