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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pdf/mhs-IV-epc-grand-rounds-slides.pptx
January 01, 2023 - 2019-Widescreen
AHRQ Evidence-based Practice Center Program
Grand Rounds Series
Making Healthcare Safer … Associate Professor of Critical Care Medicine, Anesthesiology and Surgery – Johns Hopkins University; … Principal – Leavitt Partners
8
Making Healthcare Safer Portfolio
Farzana Samad, Pharm.D., FISMP … 10
MHS: Making Healthcare Safer; PSPs: patient safety practices
Could be approached from a harm area … Primary Removed hospitalist physician, added critical care nurse Hospital Standardized Mortality Ratio
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/ambulatory-safety_research-protocol.pdf
July 24, 2015 - III. … from Key Informants and AHRQ on which patient safety practices
(PSPs) covered in Making Health Care Safer … Making Health Care Safer II: An
Updated Critical Analysis of the Evidence for Patient Safety Practices
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - that allow for easy reporting of events, (ii) standardizing performance review and
assessment, and (iii … clinicians consider all appropriate diagnoses.(13,14)
Balancing systems and individual accountability is critical … Lesser CS, Lucey CR, Egener B, Braddock CH III, Linas SL, Levinson W. … Reiter CE III, Pichert JW, Hickson GB. … Commentary: how can we make diagnosis safer? Acad Med. 2012;87:135-138.
[go to PubMed]
14.
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - the areas of focus in the Agency for Healthcare Research and Quality (AHRQ) report Making Healthcare Safer … III: A Critical Analysis of Existing and Emerging Patient Safety Practices . 1 Although medication … interventions provide prescribers with medication warning alerts and alternative medications that are safer … of opioid prescribing practices related to workers’ compensation in Washington State reported that safer … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices .
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 01, 2023 - III. Contents
Resources by Composite Measure 3
Composite Measure 1. … • “SBAR Report to Physician About a Critical Situation” is a worksheet/script a provider
can use … www.pharmacytimes.com/view/beatingjobstress-1010
Heavy workloads and long hours make stress management a critical … How To Use This Resource List
III. Contents
IV. … Shining a Light: Safer Health Care Through Transparency
Composite Measure 9.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-iv-patient-safety-practices-year-2.pdf
May 01, 2025 - Expert Panel, 2024-2025
Making Healthcare Safer IV
Making Healthcare Safer IV: Summary of Findings … 3Awhite_paper&f%5B4%5D=field_product_type%3Amethods_guide_chapter&sort_by=field_product_pub_date
iii … Addressing implementation barriers, such as infrastructure costs and data
transparency, is critical … Making Healthcare Safer IV. … Making Healthcare Safer IV Rapid Review.
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - the areas of focus in the Agency for Healthcare Research and Quality
(AHRQ) report Making Healthcare Safer … III: A Critical Analysis of Existing and Emerging Patient Safety
Practices.1 Although medication safety … interventions provide prescribers with medication warning
alerts and alternative medications that are safer … of opioid prescribing practices related to workers’ compensation in Washington
State reported that safer … Making Healthcare Safer III: A Critical Analysis of
Existing and Emerging Patient Safety Practices.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
August 01, 2025 - Between July 2001, when Safer I was published, and March 2013, when Safer
II was published, the AHRQ … III: A Critical Analysis of
Existing and Emerging
Patient Safety Practices
2017–2020
$1,265,000 … III,” this project resulted in a
1,403-page compendium published in March 2020. … Safer III comes 7 years after Safer II
(published in 2013) and 19 years after Safer I (published in … In Safer III, five
major threats to safety are addressed: medication management issues, healthcare-
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
June 01, 2023 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. … https://www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html .
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - problem is that clinicians then ignore both the bothersome, clinically meaningless alarms and the critical … Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn … The Making Healthcare Safer III report outlines several patient safety practices to address alert fatigue … Tailor alerts to patient characteristics and critical integrated clusters of physiologic indicators.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/hro-protocol.pdf
January 01, 2023 - Making Healthcare Safer IV: High Reliability Organization (HRO) as a Patient Safety Practice
Evidence-based … Practice Center Rapid Review Protocol
Project Title: Making Healthcare Safer IV: High Reliability … conditions before they result in adverse events.4
Respectful interaction and heedful interrelating are critical … HROs was discussed in the introduction of “Cross-cutting Patient Safety
Topics/Practices” in MHS III … Making Healthcare
Safer IV.
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www.ahrq.gov/sites/default/files/2024-11/devita-report.pdf
January 01, 2024 - clinical deterioration and who may
enable hospitals to respond more effectively to inpatient crises.i,ii,iii … http://www.metconference.com/
iii Foraida M, Braithwaite RS, DeVita MA et al. … Manuscript in press; Journal of Critical Care. … Intensive and Critical Care Nursing 1994; 10: 115-20. … To err is human: building a safer health system.
Washington, D.C.: National Academy Press.
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - that allow for easy reporting of events, (ii) standardizing performance review and assessment, and (iii … clinicians consider all appropriate diagnoses.( 13,14 ) Balancing systems and individual accountability is critical … Lesser CS, Lucey CR, Egener B, Braddock CH III, Linas SL, Levinson W. … Reiter CE III, Pichert JW, Hickson GB. … Commentary: how can we make diagnosis safer? Acad Med. 2012;87:135-138. [go to PubMed] 14.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/engaging-caregivers-protocol.pdf
August 04, 2023 - EHC Protocol: Making Healthcare Safer IV: Engaging Family Caregivers with Structured Communication for … , particularly those from an inpatient or emergency setting to an outpatient setting,
represent a critical … Making Healthcare
Safer IV. … Making Healthcare Safer III: A
Critical Analysis of Existing and
Emerging Patient Safety Practices … transitions, particularly those from an inpatient or emergency setting to an outpatient setting, represent a critical
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - Performance analysis focused on errors, and trained users of the 3 pumps had a total of 10, 18, and
42 critical … viewpoint arises when we start looking at devices, software, and even architecture through a more
critical … The Role of Health Care Organizations
Health care organizations can use HFE to select and deploy safer … pump system is not being replaced, an organization can use HFE methods to make its
existing system safer … from each IV bag all the
way to the IV catheter—beyond simply placing a label every 6 inches, and (iii
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Another, safer design could involve consolidating all bed status information, including lock status, … Unlike in aviation where safety-critical changes are quickly communicated and acted upon across the entire … infusion pump.( 14 ) In summary, medical device and health care industries can produce safer products … By designing safer medical devices based on human factors engineering principles and methods, patient … Pennathur PR, Thompson D, Abernathy JH III, et al.
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psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - A policy that makes today's patients a bit safer at the
cost of larger harm to patients later would … Communication failures in patient sign-out
and suggestions for improvement: a critical incident analysis … Fletcher KE, Davis SQ, Underwood W III, Mangrulkar RA, McMahon LF Jr, Saint S. … Fletcher KE, Underwood W III, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S.
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Care Medicine
and the Society of Critical Care Medicine.(6) The guidelines recommend careful planning … factor for errors and adverse
events.(12) Moreover, handover within and between units can result in critical … team; (ii) assessment
of the patient after transport to determine any deterioration in condition; (iii … Warren J, Fromm Jr RE, Orr RA, Rotello LC, Mathilda HM; American College of Critical Care Medicine. … To Err Is Human: Building a Safer Health System.
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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - Performance analysis focused on errors, and trained users of the 3 pumps had a total of 10, 18, and 42 critical … Another viewpoint arises when we start looking at devices, software, and even architecture through a more critical … create human factors design standards for all future infusion devices.( 10 ) Designing efficient, yet safer … pump system is not being replaced, an organization can use HFE methods to make its existing system safer … from each IV bag all the way to the IV catheter—beyond simply placing a label every 6 inches, and (iii
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - McGreevey III, MD | November 1, 2016
View more articles from the same authors. … McGreevey III, MD Order sets are intended to increase consistent, evidence-based practice, prevent errors … Adherence to established principles of order set design, decision support, and governance is critical … McGreevey JD III. Order sets in electronic health records: principles of good practice. … SAFER Guides: Computerized Provider Order Entry With Decision Support.