-
psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
April 27, 2022 - Accurately assessing patients' abilities to care for themselves after discharge can be difficult and requires … Preventing Adverse Events After Discharge Ensuring safe care transitions requires a systematic approach
-
psnet.ahrq.gov/primer/root-cause-analysis
March 30, 2022 - Task-related A patient requires emergency surgery which delays his dialysis treatment due to a misplaced … As detailed in a 2016 Annual Perspective , safety experts agree that effective error analysis requires
-
psnet.ahrq.gov/issue/promoting-health-care-safety-through-training-high-reliability-teams
January 06, 2018 - The authors conclude that an ongoing effort to improve safety through an emphasis on teams requires understanding
-
psnet.ahrq.gov/issue/physician-understanding-and-ability-communicate-harms-and-benefits-common-medical-treatments
September 28, 2016 - Shared decision-making is critical to high quality care and requires that providers accurately communicate
-
psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
May 30, 2012 - The protocol requires performing a time out prior to beginning surgery, a practice that has been shown
-
psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery
November 26, 2008 - The Joint Commission's Universal Protocol for prevention of wrong-site surgeries requires performing
-
psnet.ahrq.gov/issue/fda-101-how-use-consumer-complaint-system-and-medwatch
February 15, 2024 - FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires
-
psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The innovation also requires that team members have skills and experience with aggregate root-cause analysis … The innovation also requires that team members have skills and experience with aggregate root-cause analysis … opinions
Contingency plans (e.g., if supplies run out)
Sustaining This Innovation
Sustainability requires
-
psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - Addressing the training, experience, and
general competence of physicians practicing in EDs requires … Because emergency care requires the cooperation of
multiple physicians, failure to accurately transfer … Conclusions
ED safety requires a multi-faceted approach that addresses provider knowledge, experience
-
psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - This requires an
effective system to incorporate evidence-based guidelines into the care of all patients … Like most patient safety interventions, successful control of MRSA requires a combination of interventions … Like most
patient safety activities, this requires a comprehensive approach focusing on the system and
-
psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - change appear to be the most successful in achieving safety
goals.(11,12) Promoting change not only requires … leadership and "cheerleading"—it also requires
measurement to ensure that cultural goals are being … effect.(12)
"You Can't Find a Fever If You Don't Take a Temperature"
Changing a culture ultimately requires
-
psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - well-controlled trials are often superior to those seen in “real-world” practice.( 4,5 ) Bridging that gap requires … of care, and large numbers of staff, is a high-risk area for adverse events.( 10,11 ) It, therefore, requires … Simple additions, such as changing the formulation of children’s ibuprofen elixir that will be stocked, requires
-
psnet.ahrq.gov/issue/maalox-total-relief-and-maalox-liquid-products-medication-use-errors
February 17, 2021 - July 10, 2015
FDA requires label warnings to prohibit sharing of multi-dose diabetes
-
psnet.ahrq.gov/issue/ismp-survey-provides-insights-preparation-and-admixture-practices-outside-pharmacy
December 02, 2020 - May 12, 2021
Safety with nebulized medications requires an interdisciplinary team approach
-
psnet.ahrq.gov/issue/fda-cautions-about-dose-confusion-and-medication-errors-antibacterial-drug-zerbaxa
April 08, 2020 - FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires
-
psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only
February 10, 2021 - January 25, 2017
FDA Drug Safety Communication: FDA requires labeling changes for prescription
-
psnet.ahrq.gov/issue/nonfatal-unintentional-medication-exposures-among-young-children-united-states-2001-2003
February 27, 2019 - October 25, 2017
FDA requires label warnings to prohibit sharing of multi-dose diabetes
-
psnet.ahrq.gov/issue/fda-funding-available-research-aimed-reducing-preventable-harm-medication
October 28, 2020 - FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires
-
psnet.ahrq.gov/issue/medical-error-reporting-system-could-boost-patient-safety
December 14, 2022 - August 1, 2007
Requires DHSS to make reported information about certain adverse events
-
psnet.ahrq.gov/issue/national-prescription-drug-take-back-day
May 20, 2020 - FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires