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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - ); (ii) development and implementation of service-oriented clinical decision support (CDS) ( 7 ); (iii … Toward that end, we developed the Office of the National Coordinator–approved SAFER (System Assurance … ii) incorrect or incomplete use of EHR technology by those within the health care organization; and (iii … SAFER Guides. … It's easy in retrospect to be critical, it was too much money, it was too fast, it was too x , it was
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - events in ambulatory and long term care settings.12
One recent funding opportunity, Making Health Care Safer … Making healthcare safer III: a critical analysis of existing
and emerging patient safety practices.
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - in ambulatory and long term care settings. 12 One recent funding opportunity, Making Health Care Safer … Making healthcare safer III: a critical analysis of existing and emerging patient safety practices .
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - of three components, known as the "fire triad" ( 4 ): (i) an ignition source, (ii) an oxidizer, and (iii … However, the safest approach to OR fires is prevention, especially critical for on-the-patient fires … must recognize the fire triad in the OR (i.e., oxidizer, ignition source, and fuel), including the critical … September 7, 2011
Engineering the system of communication for safer surgery.
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - We lack critical supports like electronic health records and personal health records. … There's a critical balance. … the frontline delivery system and that we're probably not focusing their efforts on some of the most critical … plan for measurement and reporting, (ii) identifying core metrics for measurement and reporting, and (iii … To Err Is Human: Building A Safer Health System.
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psnet.ahrq.gov/node/49424/psn-pdf
November 01, 2003 - Outcomes research is beginning to address these critical questions, and
it is driving policy decisions … hospitals in the State of Ohio, a complete surgical team was
immediately available in 100% of Level III … can give providers a set of tools to make their responses
more rational, productive, and ultimately safer
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - plan for measurement and reporting, (ii) identifying core metrics for measurement and reporting, and (iii … foundation for reporting systems that facilitate the capture of quality and patient safety practices critical … To Err Is Human: Building A Safer Health System. … We lack critical supports like electronic health records and personal health records. … There's a critical balance.
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - Starting therapy in an elderly patient with a single agent is generally a safer strategy, and many patients … the geriatric patient, (ii) the importance of anticipating confusion from sound-alike medications, (iii … .( 10 ) Explaining that some pills contain multiple pharmacotherapeutic agents must be considered a critical … To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
3.
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - plan for measurement
and reporting, (ii) identifying core metrics for measurement and reporting, and (iii … foundation for reporting systems that facilitate the capture of quality and patient
safety practices critical … To Err Is Human: Building A Safer Health System.
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Nearly 10% of the errors identified resulted in or contributed to
patient harm.(6)
Making PN Use Safer … standardization of the process and the expertise of those involved, the number of patients
receiving PN is a critical … In the absence of built-in decision support, the critical step of pharmacist review
becomes paramount … Unfortunately,
commercially available pre-made PN formulations are not safer in the absence of a standardized … Poh BY, Benjamin S, Hayward TZ III.
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - computerized physician order entry (CPOE) system, which had a
menu of several possible doses of vasopressin; (iii … the ICU
nurses brought a group of nursing students to the patient’s bedside for an introduction to critical … incorrectly written by a resident physician after he received a verbal order from
his supervising critical … Finally, we suggest that all changes be re-evaluated periodically to ensure the new process is indeed safer
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psnet.ahrq.gov/issue/computer-based-provider-order-entry-cpoe
July 20, 2022 - May 5, 2017
Honesty and transparency, indispensable to the clinical mission--Parts I-III … April 13, 2022
Choosing wisely in clinical practice: embracing critical thinking, striving … for safer care.
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - computerized physician order entry (CPOE) system, which had a menu of several possible doses of vasopressin; (iii … the ICU nurses brought a group of nursing students to the patient’s bedside for an introduction to critical … was incorrectly written by a resident physician after he received a verbal order from his supervising critical … Finally, we suggest that all changes be re-evaluated periodically to ensure the new process is indeed safer
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - safety,
but also how this knowledge can enhance clinical and organizational practices and support safer … The Institute of Medicine's landmark patient safety
publication, To Err is Human: Building a Safer Health … It is critical that researchers test the effectiveness of prospective tools and resources in real world … constructing
measures that shape clinical definitions, electronic specifications, and interoperability; and (iii … research and its application, more interdisciplinary
research initiatives will enable and support safer
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - Nearly 10% of the errors identified resulted in or contributed to patient harm.( 6 ) Making PN Use Safer … standardization of the process and the expertise of those involved, the number of patients receiving PN is a critical … In the absence of built-in decision support, the critical step of pharmacist review becomes paramount … Unfortunately, commercially available pre-made PN formulations are not safer in the absence of a standardized … Poh BY, Benjamin S, Hayward TZ III.
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psnet.ahrq.gov/web-mm/waiting-too-long
February 01, 2013 - Outcomes research is beginning to address these critical questions, and it is driving policy decisions … hospitals in the State of Ohio, a complete surgical team was immediately available in 100% of Level III … can give providers a set of tools to make their responses more rational, productive, and ultimately safer
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - the second victim
recovery process: (i) chaos and accident response, (ii) intrusive reflections, (iii … Awareness of the second victim phenomenon and proactive institutional response planning are critical … To Err is Human: Building a Safer Health System.
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - it's clear that the
infusion of physicians unfamiliar with the local clinical microsystems is also critical … Making July safer: simulation-based mastery learning during
intern boot camp. … Highstead RG, Johnson LC, Street JH III, Trankiem CT, Kennedy SO, Sava JA.
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - For many patients, while PCA is considered safer than continuous intravenous opioid administration, and … has fewer logistical considerations than epidural analgesia, it can result in critical respiratory … years
Female gender
American Society of
Anesthesiologists (ASA)
physical status classification III … Sarina Fazio, PhD, RN
Postdoctoral Research Fellow,
Division of Pulmonary, Critical Care and Sleep … Firestone, PharmD, BCCCP
Critical Care Pharmacist,
UC Davis Health
Assistant Clinical Professor,
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psnet.ahrq.gov/Information/Editor
December 01, 2015 - He is board certified in anesthesiology, critical care medicine and transesophageal echocardiography. … quality for over eight years, most recently writing several chapters of the AHRQ Making Healthcare Safer … III report. … residency in general surgery at the University of California, Davis, and fellowship in trauma and surgical critical