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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - At Intermountain, I worked on the evaluation of the Mental Health Integration program. … Intermountain, where I worked for 12 years, had an advanced training program that started in the late … Intermountain had something they called the clinical program infrastructure. … The organization was structured for improvement, with nine clinical program areas. … Health technology, quality and safety in a learning health system.
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Health technology, quality and safety in a learning health system. … At Intermountain, I worked on the evaluation of the Mental Health Integration program. … Intermountain, where I worked for 12 years, had an advanced training program that started in the late … Intermountain had something they called the clinical program infrastructure. … The organization was structured for improvement, with nine clinical program areas.
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - , residency
programs, and even fellowship training … occurred in 2021.11 Over the past several
decades, there has been increasing attention to improving the quality … Some challenges in
developing an outpatient palliative care program include inadequate
reimbursement … • Outpatient or home-based palliative care programs should be utilized to
avoid gaps in palliative … A questionnaire to measure general practitioners' attitudes to their role in the management of patients
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - of adverse events in hospitals,
94% of the events involved physician care.(13) Although physician quality … Rockville, MD: Agency for Healthcare Research and Quality. [Available at]
5. … errors involving
unfractionated and low-molecular-weight heparin in three patient safety reporting programs … Closing the loop: follow-up
and feedback in a patient safety program. … Palermo, MD, MMM, FACS, VP, Chief Medical Officer, Chief Quality Officer, Health First, Inc.;
and Ellen
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - Chalapathy Venkatesan is the Chief Quality and Safety Officer, and Kathy Helak is the
Assistant Vice … Chalapathy Venkatesan: I am the Chief Quality and Safety Officer at Inova Health System. … As a healthcare system, we have a lot of
external objective measures of high performance in safety, … Still, underneath those objective measures, we saw inconsistent performance and recurrent safety
events … would provide to other organizations
that are interested in integrating Safety-II into their safety programs
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … At 2 am, when the nurse came to measure the hourly fingerstick, she found the patient somnolent, tremulous … Quality improvement efforts, exemplified by those of the Institute for Healthcare Improvement in its … Medication Education Program. Accessed April 20, 2004.
8. Lillis K. Automated dosing.
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - A study that examined the American College of Surgeons National Surgical Quality Improvement
Program … This protocol
sets expectations, minimizes variability of care, and improves quality through the application … evidence-based clinical care protocols can minimize variability
of care, set team expectations, and improve quality … or geriatrics and orthopedics reduces medical complications
and improves mortality, function, and quality … project was funded under contract number 75Q80119C00004 from the Agency for Healthcare
Research and Quality
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - ETCO2) as well as pulse oximetry (SpO2) to monitor patient oxygenation and ventilation.31 Capnography
measures … Hospital Quality Institute;2009.
28. Nashett R, Adams C, Stashek C. … project was funded under contract number 75Q80119C00004 from the Agency for Healthcare
Research and Quality
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psnet.ahrq.gov/sites/default/files/2020-07/spotlight_nstemi.pdf
January 01, 2020 - unnecessary, expensive testing or
provide a false sense of reassurance
- If this leads to a gap in quality … Diagnostic Errors: Agency for Healthcare Research and Quality; 2019 [updated September 2019. … Pharmacotherapy Self-Assessment Program, seventh edition (PSAP-VII) Cardiology.2020:179-99.
14. … Initial Results from a Cardiac Curbside Program. … Circulation: Cardiovascular Quality and Outcomes. 2014;7(A346).
44.
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Bindman was appointed as Director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016 … What was remarkable about this program, and AHRQ was an early supporter of it and evaluated the work … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … BMJ quality & safety. 2011 Dec 1;20(12):1027-34. … BMJ quality & safety. 2017 Feb 1;26(2):131-40. … BMJ Quality & Safety. 2005 Apr 1;14(2):80-6. … BMJ quality & safety. 2018 Nov 1;27(11):892-901.
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Education and mentoring
There is a dearth of effective strategies to teach and foster high-quality and … communicates
clinical care, it also serves as a record of care for purposes of professional billing, quality … Feedback is a proven strategy for improving the quality of trainee
progress notes, but such interventions … Time spent on clinical
documentation: a survey of internal medicine residents and program directors. … The impact of feedback to medical housestaff on chart documentation and quality of care in
the outpatient
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … For this Perspective, we benefited from the input and insights of Gordon Schiff, MD, the Quality and … delivery systems to leverage their infrastructure and facilitate the creation of ambulatory care safety programs … Agency for Healthcare Research and Quality; 2020.
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psnet.ahrq.gov/node/33676/psn-pdf
November 01, 2008 - Such confidence in
putting in place programs to prevent catheter-related urinary tract infections to … should focus on is making sure that the processes that have been
shown in randomized trials or high-quality … What would be useful from a regulatory point of view is to evaluate some of these process measures to
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - Cochrane review demonstrated no difference between HME and HH regarding airway blockages, with overall low quality … mortality in one systematic review of controlled trials in the perioperative setting.17
Capnography measures … Patterns, Safety, and Rationale for Tracheostomy Tube Changes: A Survey of Otolaryngology Training Programs
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - you've done but also your evaluation of the Robert Wood Johnson "Transforming Care at the Bedside" program … JN : We've been talking about safety, reliability, and quality. … and safety to high levels of quality and safety. … Similarly, the Community Health Center program has added more than 3000 nursing positions since 2009, … The Affordable Care Act also created a $1.5 billion maternal and child home visitation program, emphasizing
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - equipped to provide definitive dental treatment and instead only provide patients with
temporizing measures … Up-to-date recommendations for communications, protocols, and physical measures must
be in place to … skill-
based active errors (e.g., leaving cement in the sulcus), can all jeopardize patient safety and quality … psnet.ahrq.gov//#69
https://psnet.ahrq.gov//#70
information on Medicaid and Children’s Health Insurance Program … Studies find teledentistry programs increase patient access to dental services.
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psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
March 01, 2017 - MDW : The first thing to say about the Michigan program was that it had a very good technical intervention … When the attempt was made to take it to England without understanding what was there, the program was … That means a really sophisticated understanding of both the components of your program and its mechanisms … MDW : That is, in fact, where my current research program is going. … September 21, 2022
Perspective
Building a Safety Program
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - National
Action Plan to Advance Patient Safety, released by the Agency for Healthcare Research and Quality … together with external evidence to continuously learn, disseminate knowledge, and
facilitate high quality … An example of using the EHR as part of a learning health system is the “Learn from Every Patient
Program … data and best practices
to work toward the common goal of minimizing patient harm and delivering high quality … Health technology, quality and safety in a learning health system.
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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - We didn't think about how technology would enable novel
workflows that would improve quality, safety … Before you know it, CMS said there are 40 quality measures, and here are the things that need to be … But if you were to design a program from scratch for a country, how would you do it? … We've built all
these things, and the way we did it is we created microservices—little application program … are not just because the technology is cool but because it's going to help us deliver
safer, higher quality