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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
January 01, 2023 - .............................................................................................. 10
III … this free action plan from the IHI that provides clear
directions to make significant advances toward safer … These are critical to creating a safety culture and
nurturing high reliability within a healthcare organization … III. … Resources by Additional Measures
Workplace Safety Reporting
Work Stress/Burnout
III.
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psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
March 01, 2012 - On the other hand, many patients and advocates point out that the courts are critical—if not essential—to … Given the number of stakeholders with varying interests, making decisions based on solid data will be critical … malpractice claims and adverse events due to negligence—results of the Harvard Medical Practice Study III … Maybe we need to get our arms around them and make them safer. I think that's the next frontier. … Ultimately it's not about claims at all, it's about making people safer.
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - Maybe we need to get our arms around them and make them safer. I think that's the next frontier. … Ultimately it's not about claims at all, it's about making people safer. … On the other hand, many patients and advocates point out that the courts are critical—if not essential—to … Given the number of stakeholders with varying interests, making decisions based on solid data will be critical … malpractice claims and adverse events due to negligence—results of the Harvard Medical Practice Study III
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/workplace-safety-resources.pdf
May 01, 2023 - III. Contents
Resources by Composite Measure 3
Composite Measure 1. … download this free action plan that can provide clear directions to make
significant advances toward safer … and leaders to act on the report, and taking
personal responsibility for one’s actions, which are critical … • Identifying the critical needs and priorities to support the well-being of clinicians,
including … How To Use This Resource List
III. Contents
IV.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
January 01, 2019 - www.ahrq.gov/sops/surveys/hospital/index.html
mailto:SafetyCultureSurveys@westat.com
ii
III … The Comprehensive Unit-based Safety Program (CUSP) is a method that can help clinical teams
make care safer … ProvideFeedbacktoFrontLineStaff.aspx (requires
free account setup and login)
Feedback to the front-line staff is a critical … /Shining-a-Light-Safer-Health-Care-Through-
Transparency.aspx (requires free account setup and login) … /Tools/SBARTrainingScenariosandCompetencyAssessment.aspx
12
• “SBAR Report to Physician About a Critical
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www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
January 01, 2025 - • Applying Critical Thinking – Case-based training materials to support the development of
expertise … III. … Critical behaviors prompts from applied human reliability (e.g., the “STAR” prompt: Stop,
Think, Act … Agency Self Assessment† NA NA 91.8% 98.2%
Critical Thinking Skills Development 97.7% 98.4% 94.2% 97.6% … To Err is Human: Building a Safer Health System.
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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/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/perspective/telemedicine-and-patient-safety
September 01, 2016 - usability and efficacy trials, such evaluations should not be limited to academic medical settings; (iii … Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project … Lewis TL, Wyatt JC. mHealth and mobile medical apps: a framework to assess risk and promote safer use … RT : This is why I think it is so critical that physicians are taking the lead and must take the lead … of medical malpractice claims against medical oncologists from a national database: implications for safer
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/appa.html
July 01, 2018 - organizations acknowledge the magnitude of this "implementation gap":
The AHRQ report, Making Health Care Safer … Similarly, order sets and critical pathways not supported by a healthy quality improvement framework … junctures (e.g., admission to the hospital, admission or transfer to the critical care unit, changes … Heit JA, Silverstein MD, Mohr DN , Petterson TM, O’Fallon WM , Melton LJ III. … Comments on special roles, type of work (e.g., critical care vs. ward), or degree of involvement can
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/appa.html
July 01, 2018 - organizations acknowledge the magnitude of this "implementation gap":
The AHRQ report, Making Health Care Safer … Similarly, order sets and critical pathways not supported by a healthy quality improvement framework … junctures (e.g., admission to the hospital, admission or transfer to the critical care unit, changes … Heit JA, Silverstein MD, Mohr DN , Petterson TM, O’Fallon WM , Melton LJ III. … Comments on special roles, type of work (e.g., critical care vs. ward), or degree of involvement can
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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/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - 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 depression … years
Female gender
American Society of Anesthesiologists (ASA) physical status classification III-V … 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/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - described 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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effectivehealthcare.ahrq.gov/sites/default/files/pdf/osteoporosis-vibration-therapy_research-protocol.pdf
January 01, 2020 - Alternative therapies, including
weight-bearing exercise, may also increase bone density16,17 and are safer … III. … has a potential conflict of interest but is still deemed to have a viewpoint or specific
expertise critical … What criteria (clinical effectiveness, safety, FDA approval, market value, others)
are the most critical … and trends in low femur
bone density among older US adults: NHANES 2005–2006 compared with
NHANES III
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - conduct
fall risk screening, (ii) develop a tailored fall prevention plan for individual patients, and (iii … screening for fall risk, (ii) identifying interventions tailored
to patient-specific areas of risk, and (iii … In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
January 29, 2008 - behavior-based evaluation of a gradual, voluntary CPOE implementation
found that CPOE medication orders were safer … To err is human: Building a
safer health system. … Computerized
physician order entry and medication errors in a
pediatric critical care unit. … false-positive coagulase negative
staphylococcus blood and cerebrospinal fluid culture
rates in a level III … An update, an
extension, and some critical needs. Hum Factors 2006;
48: 392-412.
71.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-2025.pdf
January 01, 2025 - citations*
Geographical Distribution of Funding
Approaches to Improving Patient Safety
(No. of Projects)iii … HIT-HIE Patient Safety Improvement Targets
(No. of Projects)iii
*as of April 2, 2025
i Health information … iii The total number of projects is greater than 60 as some projects used more than one approach to improving … diagnoses mentioned in simulations, leading to
development of a comprehensive training toolkit for safer … over, providing that information
to pharmacists, and then having pharmacists and physicians discuss safer
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-references.html
January 01, 2024 - Diagnostic errors in pediatric critical care: a systematic review. … A critical appraisal of AHRQ’’s ““diagnostic errors”“ report. … Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. … 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/web-mm/july-syndrome
July 01, 2011 - 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.