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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - Implementation of large-scale safety improvement programs requires learning
organizations—organizations … Implementing a Program of Patient Safety in Small Rural Hospitals. … Explaining Michigan: developing an ex post theory of a quality improvement program. … Implementing a Program of Patient Safety in Small Rural Hospitals. … Explaining Michigan: developing an ex post theory of a quality improvement program.
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - We help organizations to build patient and family advisory programs. … Whereas, if you implement PFE in a safety program, for instance, it becomes really authentic when you … bring patients in for the development and design stage of the program, when the person’s lived experience … getting information you think you’ll need with a survey, so what are the chances a quality improvement program … J Fam Pract. 2000;49(9):796-804. [ PubMed ]
[4] Gateways to PFA Program.
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psnet.ahrq.gov/issue/talking-patients-about-other-clinicians-errors
October 27, 2021 - April 17, 2024
Can communication-and-resolution programs achieve their potential? … April 13, 2011
Communication-and-resolution programs: the challenges and lessons learned … February 17, 2017
Disclosure, apology, and offer programs: stakeholders' views of barriers … December 4, 2013
A comprehensive quality assurance program for personnel and procedures
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psnet.ahrq.gov/node/73287/psn-pdf
May 19, 2021 - influence-opioid-prescription-policy-overdoses-and-related-adverse-effects-primary-care
https://psnet.ahrq.gov/issue/four-states-robust-prescription-drug-monitoring-programs-reduced-opioid-dosages … coupling-policymaking-evaluation-case-opioid-crisis
https://psnet.ahrq.gov/issue/implementation-prescription-drug-monitoring-programs-associated-reductions-opioid-related
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psnet.ahrq.gov/node/61071/psn-pdf
January 01, 2021 - first-do-no-harm-marshaling-clinician-leadership-counter-opioid-epidemic
https://psnet.ahrq.gov/issue/four-states-robust-prescription-drug-monitoring-programs-reduced-opioid-dosages … https://psnet.ahrq.gov/issue/four-states-robust-prescription-drug-monitoring-programs-reduced-opioid-dosages
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psnet.ahrq.gov/node/46959/psn-pdf
August 20, 2018 - This study randomized
internal medicine residency programs to either standard duty hour rules from the … Interns in
flexible duty hour programs reported worse well-being and educational satisfaction compared … As in a prior study of surgical training, program directors of flexible duty
hour programs reported … rates-medication-errors-among-depressed-and-burnt-out-residents-prospective-cohort-study
https://psnet.ahrq.gov/issue/program-director-perceptions-surgical-resident-training-and-patient-care-under-flexible-duty … https://psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
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psnet.ahrq.gov/issue/teamwork-obstetric-critical-care
January 31, 2024 - history of teamwork training in aviation and in health care and summarizes the evidence behind existing programs … health care, and the research that is still needed to fully understand the outcomes associated with such programs … December 12, 2012
The case for simulation as part of a comprehensive patient safety program
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psnet.ahrq.gov/node/33598/psn-pdf
June 15, 2024 - and quality improvement efforts, which have
helped define key elements of successful fall prevention programs … There are two overarching considerations in planning a fall prevention program. … Promoting mobility and activity has therefore become a key component of programs to improve outcomes … The evidence regarding the efficacy of specific fall prevention programs has been mixed. … AHRQ has published toolkits with
implementation guides for fall prevention programs in hospitalized
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psnet.ahrq.gov/node/33780/psn-pdf
July 01, 2015 - While many UME and GME programs have implemented didactics
or online courses to meet these requirements … The intent of this program is to evaluate the degree to which
trainees' work environment supports their … the finding that
residents and fellows are often disengaged from institutional safety programs and … The MOC program requires that physicians demonstrate continued competence in
https://psnet.ahrq.gov/ … In the case of the more recent
CLER program, empirical results are likely a few years away.
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psnet.ahrq.gov/node/73084/psn-pdf
March 31, 2021 - Organizations are encouraged to implement programs to reduce burnout and support HCW
well-being. … relationship-between-professional-burnout-and-quality-and-safety-healthcare-meta-analysis
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-gynecology
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psnet.ahrq.gov/node/61062/psn-pdf
January 01, 2022 - medication-errors-anesthesiology-it-time-train-example-vignettes-can-assess-
error-awareness
Incident reporting systems are central to most patient safety programs … Education programs utilizing vignettes should be utilized to raise
awareness about error reporting and
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psnet.ahrq.gov/issue/support-strategies-health-care-professionals-who-are-second-victims
December 22, 2021 - second victim support initiatives and tools and suggests involving perioperative nurses in support programs … A past PSNet perspective provides insight on the importance of second victim programs. … March 13, 2019
Case: a second victim support program in pediatrics: successes and challenges … March 3, 2019
Implementation of a second victim program in the neonatal intensive care
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - attending physicians, particularly surgeons, routinely work hours that would be prohibited in residency programs … and educational work hour structures, conducted in general surgery and internal medicine residency programs … for Surgical Trainees (FIRST) trial , published in 2015, randomized 118 general surgery residency programs … The iCompare trial, a similar study involving internal medicine residency programs, published its initial … care did not differ between groups, although educational satisfaction was lower among residents in programs
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psnet.ahrq.gov/issue/trends-pregnancy-related-deaths-and-federal-efforts-reduce-them
May 27, 2020 - Efforts funded through the programs include maternal morbidity review committees and safety bundle … May 4, 2016
Electronic Health Record Programs: Participation Has Increased, but Action
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psnet.ahrq.gov/issue/disclosing-medical-errors-prioritising-needs-patients-and-families
November 11, 2020 - The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community … January 12, 2022
Communication-and-resolution programs: the challenges and lessons learned
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psnet.ahrq.gov/primer/disclosure-errors
September 15, 2024 - Although communication-and-resolution programs are being more widely adopted, implementing such a process … literature describes the regulatory, legal, and practical considerations with implementing these programs … and Optimal Resolution (CANDOR) toolkit to help organizations implement communication-and-response programs … Patient Safety Primers
Post-Acute Transitional Services: Safety in Home-Based Care Programs
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psnet.ahrq.gov/node/43695/psn-pdf
August 02, 2015 - They predict the expansion of communication-and-
resolution programs, where providers and health systems … claims-errors-and-compensation-payments-medical-malpractice-litigation
https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters … https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters
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psnet.ahrq.gov/issue/prescribing-errors-resulting-adverse-drug-events-how-can-they-be-prevented
May 10, 2023 - the shortcomings and strengths of technology be considered when shaping medication error reduction programs … July 10, 2019
Reduce readmissions with pharmacy programs that focus on transitions from
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psnet.ahrq.gov/issue/quantifying-and-monitoring-overdiagnosis-cancer-screening-systematic-review-methods
September 15, 2021 - led by unbiased researchers show the most promise for monitoring overdiagnosis in cancer screening programs … October 12, 2016
The expanding role of antimicrobial stewardship programs in hospitals … trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - For example, one institution developed a pharmacist-led prior authorization drug request program with … The program resulted in savings not only in drug costs, but also in avoided costs related to potential … Advancing Medication Stewardship Antibiotic stewardship programs have been proven effective at improving … As evidence continues to demonstrate the success of stewardship programs, medication stewardship could … America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program