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psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
July 20, 2022 - The reviewers did find evidence of significant quality problems among both preventable and non-preventable … November 12, 2014
Relationship between preventable hospital deaths and other measures … December 4, 2013
Explaining Matching Michigan: an ethnographic study of a patient safety program … patients on medical wards: self-assessment of quality of care is suboptimal. … February 23, 2011
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Hospitals
Quality
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - created a system that facilitated poor clinical performance.( 6 ) Internal data from our own residency program … , we should define standards for the most important aspects of outpatient training and find ways to measure … High-performing practices must also measure care outcomes and engage residents and all team members in … Ambulatory training practices should measure the effects of structure on patient care outcomes and develop … Vilter Professor of Medicine Program Director, Internal Medicine University of Cincinnati Academic Health
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psnet.ahrq.gov/issue/association-safety-program-improving-antibiotic-use-antibiotic-use-and-hospital-onset
July 20, 2022 - Study
Association of a Safety Program for Improving Antibiotic Use with antibiotic … empowered to improve their own antibiotic use in conjunction with traditional antibiotic stewardship programs … Assessment of changes in visits and antibiotic prescribing during the Agency for Healthcare Research and Quality … Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic. … August 25, 2010
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Hospitals
Quality
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - BOOST provides a full implementation toolkit to help institutions implement this and other programs to … Process measures might include patient/family caregiver understanding of treatments, follow-up care required … Learn quality improvement techniques: Understanding the principles, strategies, and tools for quality … improvement is critical before the success of any program to improve discharge education. … Rehospitalizations among patients in the Medicare fee-for-service program.
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and … found to improve key communication behaviors, like family and nurse engagement on rounds, and several measures … Institute of Medicine Committee on Quality of Health Care in America. … Changes in medical errors after implementation of a handoff program. … residency program.
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psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs-common-injury-sites
August 02, 2015 - 2019
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Developing electronic clinical quality … measures to assess the cancer diagnostic process. … December 14, 2016
Improving patient safety: effects of a safety program on performance … View More
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Children's Hospitals
Health Care Providers
Quality
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psnet.ahrq.gov/issue/error-management-lessons-aviation
September 13, 2011 - use of error data in aviation, and how those processes catalyzed improvements in safety practices and programs … Resources From the Same Author(s)
Teaching teamwork during the Neonatal Resuscitation Program … February 6, 2019
Patient Safety and Quality Improvement. … January 23, 2019
Using the Communication and Teamwork Skills (CATS) assessment to measure … March 28, 2011
The Safety and Quality of Health Care: Where are We Now?
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psnet.ahrq.gov/issue/facilitators-and-barriers-care-transitions-comparing-perspectives-hospital-and-community
July 21, 2021 - Psychological impact and recovery after involvement in a patient safety incident: a repeated measures … March 12, 2025
A clinical pharmacist-led transitions of care program for veterans with … 2023
Annual Perspective
Improving Diagnostic Safety and Quality … 2011
Using a multi-method, user centred, prospective hazard analysis to assess care quality … 14, 2011
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Hospitals
Home Care
Quality
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psnet.ahrq.gov/issue/instruments-and-warning-signs-identifying-and-evaluating-frequency-adverse-events
July 20, 2022 - Assessment of changes in visits and antibiotic prescribing during the Agency for Healthcare Research and Quality … Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic. … January 15, 2025
Moving towards a core measures set for patient safety in perioperative … 2023
Annual Perspective
Improving Diagnostic Safety and Quality … June 9, 2021
WebM&M Cases
The Safety and Quality of Long
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psnet.ahrq.gov/issue/improving-accuracy-handoff-implementing-electronic-health-record-generated-tool-improvement
January 01, 2022 - April 28, 2021
Implementing a robust process improvement program in the neonatal intensive … September 14, 2022
Integrating and evaluating the data quality and utility of smart pump … August 28, 2019
Effect of a real-time pediatric ICU safety bundle dashboard on quality … improvement measures. … September 2, 2015
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Intensive Care Units
Quality
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - In 2003, AHRQ released its Patient Safety Indicators (PSIs), a
set of quality measures shown to be associated … The AHRQ Patient Safety Indicators (PSIs) and similar measures of patient safety can be used to
screen … At the
national level, the Patient Safety and Quality Improvement Act provides confidentiality and … -2005
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
https://psnet.ahrq.gov/issue … https://psnet.ahrq.gov/issue/effects-efforts-optimise-morbidity-and-mortality-rounds-serve-contemporary-quality
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psnet.ahrq.gov/issue/development-electronic-pediatric-all-cause-harm-measurement-tool-using-modified-delphi-method
July 03, 2016 - November 15, 2018
Implementation of the I-PASS handoff program in diverse clinical environments … April 11, 2011
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Related Resources
A customized triggers program … 2010
The impact of electronic medical records data sources on an adverse drug event quality … measure.
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psnet.ahrq.gov/issue/changes-hospital-acquired-conditions-and-mortality-associated-hospital-acquired-condition
July 24, 2019 - hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program … acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality … Related Resources
Impact of repeated reimbursement penalties on hospital total quality … May 17, 2023
Association of measured quality and future financial performance among hospitals … 2012
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Hospitals
Operating Room
Quality
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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - for residents, and 5 years later an Institute of Medicine (IOM) report recommended that additional measures … Recently, the ACGME has been working with residency training programs to propose milestones for tracking … Ideally, the development of milestones would incorporate mechanisms to objectively measure competency … Additionally, programs should set explicit guidelines about when trainees should communicate with their … that we're asking people to take a system that has had very little respect for safety and few true measures
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psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis
October 19, 2022 - October 19, 2022
Implementation of the I-PASS handoff program in diverse clinical environments … February 19, 2014
Demonstrating high reliability on accountability measures at The Johns … September 8, 2010
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See More About The Topic
Hospitals
Quality
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psnet.ahrq.gov/issue/ebola-us-patient-zero-lessons-misdiagnosis-and-effective-use-electronic-health-records
June 21, 2023 - Related Resources From the Same Author(s)
Developing electronic clinical quality … measures to assess the cancer diagnostic process. … July 24, 2024
A program to provide clinicians with feedback on their diagnostic performance
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psnet.ahrq.gov/issue/large-language-models-preventing-medication-direction-errors-online-pharmacies
February 27, 2019 - June 27, 2018
Development of patient safety measures to identify inappropriate diagnosis … July 17, 2024
Use of an interactive, telephone-based self-management support program … February 22, 2011
Statewide perinatal quality improvement, teamwork, and communication
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - The Agency for Healthcare Research and Quality's Questions Are the Answer program and 20 Tips to Help … Medical Errors fact sheet, as well as The Joint Commission's Speak Up initiative, are examples of programs … family participation will always be difficult to predict, leading some to argue that a robust safety program … programs centered around patient education and encouraging patient perspectives to improve safety culture … Patient Safety Goal, The Joint Commission also provides educational resources for patients around safety measures
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psnet.ahrq.gov/node/845473/psn-pdf
March 15, 2023 - monitor patients
outside the traditional care setting using digital medical devices, such as weight scales … Historically, RPM has been used to measure symptoms of chronic conditions, such as cardiac diseases, … Patients may have experienced this through wearable devices, like Holter monitors
that can measure heart … provider associations and patient associations as a significant factor that improved or
maintained the quality … Building a real-time remote patient
monitoring patient safety program for COVID-19 patients.
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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - If we don't have any way to measure whether eyeball tests worked out a month later, then we're not going … RW: The concerns that people typically have about measurement are that the measures aren't very good … RW: So from your standpoint, the movement from fairly small process changes to more global measures … But the Matrix Program goes one step further. … The attached slide presentation outlines the program.