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psnet.ahrq.gov/issue/us-adoption-computerized-physician-order-entry-systems
April 24, 2018 - for-profit organizations the least likely, adding to the notion that these systems are not intended to provide … with CPOE standards and that changes in the reimbursement environment through federal initiatives may provide
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psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient
September 26, 2012 - The study authors provide suggestions for system improvements to prevent and ameliorate adverse events … Safety in numbers: lack of evidence to indicate the number of physicians needed to provide
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psnet.ahrq.gov/issue/disclosing-errors-and-adverse-events-intensive-care-unit
February 17, 2017 - The authors provide context to their recommended approach by discussing the scope of the problem in intensive … They provide a case example with a detailed dialogue between an attending physician, an intern, and a
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psnet.ahrq.gov/issue/expected-and-unanticipated-consequences-quality-and-information-technology-revolutions
March 02, 2011 - Burgeoning efforts to improve health care quality and to wire the health care system provide the backdrop … The author advocates for better systems that not only provide improved patient outcomes but also support
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psnet.ahrq.gov/node/50625/psn-pdf
November 06, 2019 - Special Feature discusses risks and vulnerabilities around medications in non-pediatric hospitals that
provide … The authors identify risks and provide recommendations to ensure safe
care of children including optimizing
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psnet.ahrq.gov/node/39396/psn-pdf
November 02, 2014 - Unmet Needs: Teaching Physicians to Provide Safe
Patient Care. … https://psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care
Medical schools … https://psnet.ahrq.gov/issue/unmet-needs-teaching-physicians-provide-safe-patient-care
https://psnet.ahrq.gov
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psnet.ahrq.gov/webmm/submit-case
Do not provide any personally identifiable (patient or provider) information, and do not use institution … If you would like to contact the editors, send a question, comment, or suggestion, or provide feedback … PSNet does not provide expert witness services or adjudicate claims of medical error. … Email
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psnet.ahrq.gov/node/34750/psn-pdf
May 21, 2019 - https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition
The authors provide a handbook that serves as the … of a FMEA, case studies where they have been used, and a
discussion of where and when to use FMEAs provide
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psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
May 20, 2009 - They provide a case-type example of their suggested process to illustrate their framework. … commentaries by Leape and Berwick as well as Wachter focused on progress in patient safety and provide
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psnet.ahrq.gov/issue/bridging-feedback-gap-sociotechnical-approach-informing-clinicians-patients-subsequent
January 21, 2019 - This article suggests a sociotechnical approach using information technology (IT) to provide clinician … February 16, 2022
A program to provide clinicians with feedback on their diagnostic performance
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psnet.ahrq.gov/issue/physician-attitudes-toward-family-activated-medical-emergency-teams-hospitalized-children
April 06, 2012 - In an effort to provide more timely responses to clinical deteriorations, some pediatric medical centers … knowledge and training to determine when a MET is necessary, and the belief that this responsibility could provide
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psnet.ahrq.gov/issue/unit-based-incident-reporting-and-root-cause-analysis-variation-three-hospital-unit-types
April 14, 2011 - This study sought to determine whether more localized, unit-based incident reporting systems might provide … These findings suggest that localized safety reporting systems might provide information that could promote
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psnet.ahrq.gov/issue/testing-process-errors-and-their-harms-and-consequences-reported-family-medicine-practices
June 11, 2008 - Ranging from incorrect test ordering to failure to provide test results to clinicians and patients, these … errors frequently resulted in failure to provide timely patient care.
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psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-patients
March 27, 2005 - report on an extension of the HELP clinical information system at LDS Hospital, Salt Lake City, to provide … 60-fold increase in detection of ADEs with the automated system relative to voluntary reporting and provide
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psnet.ahrq.gov/issue/developing-primary-care-patient-measure-safety-pc-pmos-modified-delphi-process-and-face
August 21, 2015 - Patients may provide valuable insights into potential safety problems. … This tool aims to provide patient perspectives to primary care organizations to focus improvement efforts
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psnet.ahrq.gov/issue/rates-medical-errors-and-preventable-adverse-events-among-hospitalized-children-following
November 12, 2014 - The Accreditation Council for Graduate Medical Education now requires residency programs to provide … January 18, 2013
Why patient summaries in electronic health records do not provide the
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psnet.ahrq.gov/node/47754/psn-pdf
April 17, 2019 - It also announces a
requirement regarding changes to prescribing information for opioids to provide … Health care providers should discuss tapering plans with patients and provide
ongoing monitoring and
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
September 01, 2005 - the Elderly
“Start low and go slow”
Anticipate confusion from sound-alike, look-alike medications
Provide … Provide Careful Instructions for
All Medications
Patient education is critical to adherence, may be … important means of preventing errors
Health care providers expected to provide comprehensive information … medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide … However, provide elderly patients with the full benefits of an optimal therapeutic regimen, including
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psnet.ahrq.gov/issue/patient-feedback-reporting-tool-opennotes-implications-patient-clinician-safety-and-quality
June 06, 2018 - Patients were asked to provide feedback and note any inaccuracies, omissions, or safety concerns in a … OpenNotes, a minority of patients elected to read the documentation; of those, the majority did not provide
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psnet.ahrq.gov/node/838319/psn-pdf
October 12, 2022 - Accreditation Council on Graduate Medical Education (ACGME) began requiring residency
programs to provide … Residency program directors were surveyed in 2019 about whether and how they provide instruction and