-
psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - evidence reviews of existing and
emerging PSPs (interventions)
► MHS I: 2001
► MHS II: 2013
► MHS III … Response
Systems: Rapid Review
19
Bradford Winters, MD, PhD (Author & Presenter)
Professor of Critical … Rapid Response Systems that Aim to Mitigate
Failure to Rescue in General Hospital Wards
• MHS III … Primary Removed
hospitalist
physician, added
critical care nurse
Hospital
Standardized
Mortality … Research 2023;16:383-394
Opioid Stewardship Interventions in
Healthcare Facilities or Systems
• MHS III
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
March 06, 2025 - Work Areas to Support Safe Practice ........................................................... 9
III … Director of Armstrong Institute Center for Health Care
Human Factors and Professor of Anesthesiology & Critical … Design Processes and Organize Work
Areas to Support Safe Practice
III. … Engineering Safe Practices Affinity Group
Page 10 of 17
III. … Design Processes and Work Areas to Support Safe Practice
Implementation Support
III.
-
www.ahrq.gov/teamstepps-program/evidence-base/teams.html
June 01, 2023 - Making healthcare safer III: A critical analysis of existing and emerging patient safety practices. 2020 … Journal of Critical Care 23(2), 188-96. Select to access the abstract .
Johnson, H. … What are the critical success factors for implementing team training in health care? … The anatomy of health care team training and the state of practice: A critical review.
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/patient-safety-practices_research-protocol.pdf
November 09, 2011 - Online: November 9, 2011
Evidence-based Practice Center Systematic Review Protocol
Project Title: Critical … Background and Objectives for the Systematic Review
The critical systematic review and analysis of … The initial list of PSPs started with the
Making Health Care Safer list of 73. … Source: www.effectivehealthcare.ahrq.gov
Published Online: November 9, 2011
III. … practice in sufficient detail that it can be
replicated, including the expected effect on staff roles
III
-
psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - We spoke with
them about their role in the development of the Making Healthcare Safer III Report and … current role that you play as well
as the role that you played in the creation of the Making Healthcare Safer … conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
https://psnet.ahrq.gov/issue/making-healthcare-safer-iii … SH: If someone is not familiar with the Making Healthcare Safer Report, what is your short
explanation … SH: Were there any particular technologies in the report that address critical new or emerging
issues
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-patient-family-engagement.pdf
July 01, 2023 - prevent, report, or mitigate harms to patients and
what new evidence has been published since the MHS III … restricting the search to
studies published recently (i.e., since 2019 when the search was done for the MHS III … interest
Timing Original studies published since
2019, the year of the search done
for the MHS III … Making Healthcare Safer IV. … prevent, report, or mitigate harms to patients and what new evidence has been published since the MHS III
-
psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - lines placed outside the hospital in patients
received on transfer (and writing on the dressing), (iii … handoffs between nurses (e.g., does the patient have a central line; do they need a central line), and
(iii … training, and a safety culture that reduce the risk of injury by making it easier to
know what to do and safer … medications;
the residents consider the physiology and greatest source of danger for the patient that day), (iii … Professor, University of Cincinnati College of Medicine, Division of Pulmonary, Critical
Care, and
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/fatigue-sleepiness-protocol.pdf
July 01, 2023 - Making Healthcare Safer IV: Fatigue and Sleepiness of Clinicians Due to Hours of Service
1 … Patient safety risks due to fatigue and sleepiness of
healthcare workers were not addressed in MHS III … Making Healthcare Safer IV. … Making health care safer: a critical analysis of
patient safety practices. … Making health care safer II: an updated critical
analysis of the evidence for patient safety practices
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitresourcelist.pdf
January 01, 2019 - https://www.ahrq.gov/sops/surveys/hospital/index.html
mailto:SafetyCultureSurveys@westat.com
ii
III … Safety Assurance Factors for EHR Resilience (SAFER) Guides
https://www.healthit.gov/safer/
The SAFER … StratisHealth Health Information Technology Toolkit for Critical Access and Small Hospitals
http://www.stratishealth.org … /expertise/healthit/hospitals/htoolkit.html
The Health Information Technology Toolkit for Critical … ) Guides
StratisHealth Health Information Technology Toolkit for Critical Access and Small Hospitals
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
April 01, 2016 - was given to patient safety in the Institute of Medicine (IOM) report, To Err
Is Human: Building a Safer … implement the CANDOR process.
3 ACTIVITY: Building Project Teams
The project teams provide the critical … Phase III: Organizational Improvement and Sustainment
Phase III focuses on ensuring that the improvement … To Err is Human: Building a Safer Health System. In: Kohn LT, Corrigan JM, Donaldson MS,
editors. … Identify what you believe
are the critical success factors.
-
psnet.ahrq.gov/issue/iatrogenic-delirium-and-coma-near-miss
September 23, 2020 - July 26, 2023
Perspective
Making Healthcare Safer III Report
-
www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
July 01, 2022 - Measure Dx | 10
III. … Failure/delay in eliciting critical piece of history data
b. … Failure in weighing critical piece of history data
d. … Failure/delay in eliciting critical physical exam finding
b. … Failure in weighing critical physical exam finding
d.
-
psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - 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. … pubmed/23276846
http://www.ncbi.nlm.nih.gov/pubmed/23457151
https://www.healthit.gov/sites/default/files/safer
-
psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - lines placed outside the hospital in patients received on transfer (and writing on the dressing), (iii … handoffs between nurses (e.g., does the patient have a central line; do they need a central line), and (iii … training, and a safety culture that reduce the risk of injury by making it easier to know what to do and safer … medications; the residents consider the physiology and greatest source of danger for the patient that day), (iii … Render, MD Veterans Health Administration, National Program Director, Critical Care, Lung Disease
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/structured-handoff-rapid-research.pdf
January 01, 2025 - of
Service.4 In Making Healthcare Safer III, handoffs were discussed in “Cross-cutting
PSPs”:5 Three … Making
Healthcare Safer II: An Updated Critical
Analysis of the Evidence for Patient Safety
Practices … Making Healthcare Safer III: A Critical
Analysis of Existing and Emerging Patient
Safety Practices. … Making health care safer II: an updated critical
analysis of the evidence for patient safety
practices … Emergency handover of
critical patients. A systematic review.
-
www.ahrq.gov/patient-safety/reports/hotline/intro1.html
May 01, 2016 - Hotline Design and Development
III. Hotline Implementation and Refinement
IV. … The 2014 National Quality and Disparities Report showed that more Americans are getting safer care now … and to provide for accountability, the Institute of Medicine (IOM) report To Err is Human: Building a Safer … for standardization of reporting and the development of a common taxonomy. 2 This report listed the critical … Chapter III describes hotline implementation and refinement.
-
psnet.ahrq.gov/issue/safety-ii-and-study-healthcare-safety-routines-two-paths-forward-research
May 25, 2022 - Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer … III Report.
-
psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - 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 … 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/navigating-hierarchy-121013.pptx
January 01, 2006 - In Doctor Leads Quest for Safer Ways to Care for Patients, Dr. Peter J. … You would have thought I started World War III! … In short, to have a successful team, mutual respect and effective communication are critical. … Clearly assert concerns and suggestions
Use an assertive statement
(nonthreatening and ensures that critical
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/engaging-caregivers-rapid-review.pdf
April 01, 2024 - We rated the six pre-post studies as serious or critical risk of bias (Figure 3;
Appendix C, Table C … We rated four pre-post studies20,36,38,44 as critical risk of bias
with concerns in all domains for … One critical risk of bias, pre-post study (n=433)38 compared an
intervention called SAFER Care (developed … Making Healthcare Safer IV. … Making
Healthcare Safer III: A Critical Analysis of
Existing and Emerging Patient Safety
Practices