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psnet.ahrq.gov/issue/new-structure-attention-open-disclosure-adverse-events-patients-and-their-families
March 04, 2009 - Study
A new structure of attention? Open disclosure of adverse events to patients and their families.
Citation Text:
Iedema R, Jorm C, Wakefield JG, et al. A New Structure of Attention? J Lang Soc Psychol. 2009;28(2). doi:10.1177/0261927x08330614.
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psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error
May 05, 2021 - Commentary
Diagnostic stewardship to prevent diagnostic error.
Citation Text:
Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA. 2023;329(15):1255-1256. doi:10.1001/jama.2023.1678.
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www.ahrq.gov/es/programs/index.html?page=2
Digital Healthcare Research Advancing healthcare quality, safety, and effectiveness through the evolving digital healthcare ecosystem. More
PSNet Discover the latest literature, news, and expert commentary on patient safety topics. More
CAHPS The CAHPS program aims to advance our scientific …
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psnet.ahrq.gov/issue/resident-duty-hours-across-borders-international-perspective
February 27, 2019 - Special or Theme Issue
Resident Duty Hours Across Borders: An International Perspective.
Citation Text:
Resident Duty Hours Across Borders: An International Perspective. Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18.
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psnet.ahrq.gov/issue/creating-safer-operating-room-groups-team-dynamics-and-crew-resource-management-principles
June 11, 2008 - Review
Emerging Classic
Creating a safer operating room: groups, team dynamics and crew resource management principles.
Citation Text:
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource management principles. Semin Pe…
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psnet.ahrq.gov/issue/dangers-ignoring-beers-criteria-prescribing-cascade
October 10, 2018 - Commentary
The dangers of ignoring the Beers criteria—the prescribing cascade.
Citation Text:
DeRhodes KH. The Dangers of Ignoring the Beers Criteria-The Prescribing Cascade. JAMA Intern Med. 2019;179(7):863-864. doi:10.1001/jamainternmed.2019.1288.
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psnet.ahrq.gov/issue/assessing-impact-educational-program-decreasing-prescribing-errors-university-hospital
October 19, 2011 - Study
Assessing the impact of an educational program on decreasing prescribing errors at a university hospital.
Citation Text:
Peeters MJ, Pinto SL. Assessing the impact of an educational program on decreasing prescribing errors at a university hospital. J Hosp Med. 2009;4(2):97-101. d…
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psnet.ahrq.gov/issue/near-misses-paradoxical-realities-everyday-clinical-practice
May 04, 2012 - Study
Near misses: paradoxical realities in everyday clinical practice.
Citation Text:
Jeffs L, Affonso DD, Macmillan K. Near misses: paradoxical realities in everyday clinical practice. Int J Nurs Pract. 2008;14(6):486-94. doi:10.1111/j.1440-172X.2008.00724.x.
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psnet.ahrq.gov/issue/using-ora-explore-relationship-nursing-unit-communication-patient-safety-and-quality-outcomes
December 11, 2008 - Study
Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes.
Citation Text:
Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Me…
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psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
October 15, 2014 - Study
Classic
Medication error prevention by clinical pharmacists in two children's hospitals.
Citation Text:
Medication error prevention by clinical pharmacists in two children's hospitals. Folli HL; Poole RL; Benitz WE; Russo JC
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meps.ahrq.gov/data_files/publications/st427/stat427.shtml
January 01, 2014 - employees enrolled in employer-sponsored health insurance in 2012, 79.6 percent were enrolled in a plan … plans from firms with fewer than 100 employees had an average deductible over $1,500; while single plan … Family plan enrollees from these firms had average deductibles more than $3,300. … Coinsurance
Coinsurance is a form of medical cost sharing in a health insurance plan that requires … Percentage of private sector employees enrolled in a plan with a deductible, by firm size, 2012
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psnet.ahrq.gov/node/39960/psn-pdf
September 19, 2016 - white paper encourages hospitals to proactively develop and integrate a clinical crisis management
plan … leadership in developing a culture of safety, and the need for organizations to have a
comprehensive crisis plan … The article provides a
checklist and work plan for organizations to use in developing their plan, emphasizing
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hcup-us.ahrq.gov/db/nation/kid/KID_2003_CORE_Volume2_M-Z.pdf
January 01, 2003 - Cross Plan: Illinois 3 Private
Insurance
130 Blue Cross Plan: Unspecified 3 Private
Insurance … : Unspecified
2 TennCare Plan: Access-Med Plus
3 TennCare Plan: Blue Cross
4 TennCare Plan: Advantage … Care/Phoenix
5 TennCare Plan: Omni Care
6 TennCare Plan: Unspecified
7 TennCare Plan: Unspecified … 8 TennCare Plan: John Deere/Heritage
9 TennCare Plan: Preferred Health Partnership
A TennCare Plan … Q TennCare Plan: TennCare Select
R TennCare Plan: Better Health Plans, Inc.
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digital.ahrq.gov/sites/default/files/docs/page/2006Dye_051111comp.pdf
June 05, 2006 - chart reviews
• Trigger tool developed based on IHI
methodology
7
Medication Error Assessment Plan … meds
Many forms/doses/quantities
Adding doses to food/feeds
13
Medication Error Assessment Plan … Pediatrics: Special challenges
3-pronged approach to measuring events
Medication Error Assessment Plan … Medication Error Assessment Plan (cont'd.) … Observation
Medication Error Assessment Plan
Trigger Tool Chart Reviews
Medication Error Assessment
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-appendix-iv-roles-and-responsibilities-uspstf-members-serving-topic-lead
July 01, 2017 - staff solicits volunteers for the position of primary lead from among assigned topic leads during work plan … The leads' role on a topic begins once they have received a draft work plan on the topic. … A call is then scheduled to discuss the draft work plan. … the research plan as final. … Reviewing every comment received from the public on the draft research plan and bringing other leads
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effectivehealthcare.ahrq.gov/sites/default/files/pregnancy-horizon-scan-high-impact-1312.pdf
December 01, 2013 - Overall high-impact potential: vending machine dispensers for emergency oral
contraceptive (Plan B … *Vending machine dispensers for emergency oral contraceptive
(Plan B One-Step) to prevent pregnancy … Plan B One-Step pricing. [internet]. Santa Monica
(CA): GoodRx, Inc. … Available: http://www.goodrx.com/plan-b-
one-step.
7. … Obama administration
drops its appeal of Plan B ruling, will widen
access to drug. [internet].
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hcup-us.ahrq.gov/reports/race/annotatedslidesforR_E_report2.jsp
May 01, 2016 - Office of Minority Health: National Partnership for Action to End Health Disparities' National Plan … Racial and Ethnic Health Disparities in Colorado 2009
Colorado Health Disparities Strategic Plan … to Eliminate Minority Health Disparities Plan of Action 2010-2014
NJ
Strategic Plans … for Action
Heart Disease and Stroke Prevention Rhode Island State Plan 2009
Reducing the Burden … Ethnicity: 2010
Action Plan to Eliminate Racial/Ethnic Health Disparities in the State of Utah
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psnet.ahrq.gov/node/34692/psn-pdf
February 10, 2011 - The economic consequences of medical injuries:
implications for a no-fault insurance plan. … Implications for a no-fault insurance plan. JAMA. 1992;267(18):2487-92. … https://psnet.ahrq.gov/issue/economic-consequences-medical-injuries-implications-no-fault-insurance-plan … https://psnet.ahrq.gov/issue/economic-consequences-medical-injuries-implications-no-fault-insurance-plan
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meps.ahrq.gov/data_files/publications/st18/stat18.pdf
January 01, 2000 - than in a single coverage plan. … While almost
one-third of private-sector employees with single coverage were enrolled in a plan that … and small employers, employees
with single coverage were much less likely to contribute toward their plan … In contrast, single plan employee
contributions were greater in larger firms than smaller firms by about … If a plan
offers more than one arrangement for family coverage, premium information for a family of
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digital.ahrq.gov/sites/default/files/docs/page/2006Cain_052411comp.pdf
January 01, 2007 - Start the conversation
NOW
WORKGROUPS
COMMUNITY
ONC
INFRASTRUCTURE
20052004
FHA Strategic
Plan … Biosurveillance
• Consumer Empowerment
• Chronic Care
• Electronic Healthcare Records
• 2006 Strategic Plan … Kelly, Accenture NHIN
Keith Norris, Drew University
Identified issues
Breakout sessions
Action plan … IRB issues
Diverse needs, perceptions,
readiness to engage
Need for a coherent voice
Action plan … Office of the National Coordinator Health IT Roadmap To-Date
Agenda
Developments of the day
Action plan