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psnet.ahrq.gov/primer/falls
October 27, 2021 - More than one-third of in-hospital falls result in injury, including serious injuries such as fractures … rules for identifying high-risk patients, but none has been shown to be significantly more accurate than … They include: Multidisciplinary (rather than solely nursing) responsibility for intervention. … Staff and patient education (if provided by health professionals and structured rather than ad hoc). … Provision of safe footwear (rather than solely advice on safe footwear).
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather … than proactive, seeking to identify
and mitigate contributing factors after adverse events have occurred … But it falls
short because it emphasizes the few things that go wrong rather than seeking to understand … Rather than defining safety as the absence of
adverse events, where as few things as possible go wrong … than what goes
well.
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www.ahrq.gov/news/blog/ahrqviews/healthcare-costs-childhood-experiences.html
August 01, 2024 - estimates of ACEs–related healthcare utilization and expenditure differences based on direct observation rather … than model-based extrapolation. … fostering trauma history screenings during intake, symptoms can be viewed as normal reactions to trauma rather … than other pathologies, reducing "diagnostic error."
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psnet.ahrq.gov/node/33589/psn-pdf
September 15, 2024 - thinking to evaluate and design for safety, but they are keenly
aware that safety is an emergent, rather … than a static, property. … Near misses are viewed as
opportunities to learn about systems issues and potential improvements, rather … than as
evidence of safety. … They seek underlying rather than surface explanations.
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www.ahrq.gov/faqs/index.html?page=20
January 01, 2015 - Rather, AHRQ intends that the overall portfolio of health services research conducted and supported by … Rather, AHRQ intends that the overall portfolio of health services research conducted and supported by … funded (MYF) awards (awards in which the budget period and project period are the same and are longer than … Recipients of MYF awards must submit the PHS 2590 Non-Competing Continuation Progress Report, rather … than the RPPR, until instructed otherwise.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/50-multimodal-analgesia-facilitator.docx
June 01, 2023 - They are most effective when administered on a scheduled rather than on an as-needed basis, or PRN, and … For reference, an NNT less than 4 has strong efficacy for pain management. … Its primary side effects include hemodynamic instability, particularly when provided as a bolus rather … than an infusion. … 8
Final Thoughts
In closing, multimodal analgesia has been shown to provide better pain control than
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/nurse_empower-slides/How-CUSP-Enables-Nurse-Empowerment-Nov-15-2011-508.ppt
January 01, 2011 - Also help to extinguish the issue of blame and guilt but rather see things from a systems perspective … Issues became more rational rather than moral.
*
Slide *
CUSP: How it Empowers Nurses in the Hospital … if she covers the unit)
Expecting a solution at that meeting
Administrator tries to “solve” problem rather … than listen
Being afraid of airing dirty laundry
*
Slide *
Lessons for Your Hospital: Strategies
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/gabbay.html
October 01, 2015 - providers and staff; used a more patient-centered approach by engaging with patients in person and by phone rather … than by phone only; provided self-management support personally to patients rather than referring patients … In general, the five most-improved practices attained higher recognition levels than the five least-improved … Outreach was more difficult in urban practices, where there were more hospitals to coordinate with than
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/final-impact/lessons.html
October 01, 2015 - For example, Oklahoma’s focus on “primary health care” is broader than “primary care” and encompasses … The focus of spread activities was on creating capacity for improvement through State partnerships rather … than replication of the specific model used in the model State. … likely to change when payers begin driving the process with payment reform (i.e., payment for quality rather … than quantity of services provided).
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www.ahrq.gov/ncepcr/reports/grants-impact/lessons.html
February 01, 2017 - For example, Oklahoma’s focus on “primary health care” is broader than “primary care” and encompasses … The focus of spread activities was on creating capacity for improvement through State partnerships rather … than replication of the specific model used in the model State. … likely to change when payers begin driving the process with payment reform (i.e., payment for quality rather … than quantity of services provided).
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psnet.ahrq.gov/node/851058/psn-pdf
June 28, 2023 - peer-
reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than … misdiagnosis, and errors are more frequently systemic rather than cognitive.
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psnet.ahrq.gov/node/838017/psn-pdf
September 07, 2022 - framework to identify and reduce adultification (when children are perceived or treated as being older
than … RRC calls for systemic, rather than individual,
efforts.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/miller-rh-et
January 01, 2023 - Three practices that saw the same number of patients in less time took the gain as more personal time, rather … than seeing more patients." … alerts, only five had reminders, set by the practice, for at least one type of chronic care patient (rather … than having physicians set reminders for specific patients)....
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www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreensum.html
April 01, 2018 - we identified a number of factors that hindered implementation and that were a likely cause of lower than … patient outreach programs or experience implementing a program of this size based at the central entity rather … than the practices. … Factors increasing the odds of being screened included receiving the stool test kit directly rather than … In particular, when we sent stool test kits directly to patients rather than request cards and included
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - “Rather than being the main instigators of an accident, operators tend to be the inheritors of SYSTEM … Seek to understand rather than to judge. Ask clarifying questions and followup questions. … Go a mile deep and an inch wide rather than a mile wide and an inch deep.
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psnet.ahrq.gov/issue/getting-diagnosis-wrong
January 20, 2021 - a way to encourage physicians to spend more time on the cognitive component of forming a diagnosis rather … than simply ordering imaging tests. … December 4, 2013
Misdiagnosis is more common than drug errors or wrong-site surgery.
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psnet.ahrq.gov/node/74206/psn-pdf
December 22, 2021 - direct-oral-anticoagulant-related-medication-incidents-and-pharmacists-
interventions-hospital
While direct oral anticoagulants (DOAC) are considered safer than … Active, rather than latent, failures
contributed to most errors.
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www.ahrq.gov/research/findings/final-reports/crctoolkit/crctoolkit2.html
April 01, 2018 - This last condition is recommended rather than strictly required. … However, a number of factors hindered implementation and likely caused lower than expected screening … It also lacked experience implementing a program of this size based at the central entity rather than … Factors increasing the odds of being screened included receiving the stool test kit directly rather than … In particular, when stool test kits were sent directly to patients rather than request cards and when
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/final-report/section3.html
October 01, 2015 - columns in Table 3 should be interpreted as general indices of the average level of funds available, rather … than precise amounts spent on any given project in a particular year. … Amount reflects average level of funds available, rather than precise amount spent on any given project … A more focused grant program could have produced more definitive results on fewer topics, rather than … Generally speaking, States found that they offered each other complementary, rather than redundant, skills
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/impact-stories/better-approach.pdf
November 06, 2024 - it is
important for primary care practices to securely screen
patients and offer support services, rather … than waiting
until they show up in emergency rooms or urgent care
centers with injuries … The use of a population-based approach to IPV
screening (i.e., screening all eligible patients rather … than just
those who present with a concern) in a primary care setting
was a unique and important feature … n The intervention’s screening process was more
effective at identifying patients than nurse-led
screening