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psnet.ahrq.gov/issue/observational-study-adult-admissions-medical-icu-due-adverse-drug-events
January 28, 2015 - January 28, 2015
Impact of organizational culture on preventability assessment of selected … March 5, 2025
Overnight stay in the emergency department and mortality in older patients … 2016
Medical errors reported by French general practitioners in training: results of a survey … August 17, 2018
Understanding medical errors and adverse events in ICU patients. … Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - The only nationally representative survey of health literacy, conducted by
National Center for Educational … Offer
assistance with filling out forms and training on the patient portal. … Increase the digital health literacy of
patients through education on detecting reliable health information … A systematic review of patient medication error on self-
administering medication at home. … A Psychometric analysis of the Health Literate Healthcare
Organization-10 Item Questionnaire.
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psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md
September 11, 2023 - We spoke with him about so-called presenteeism in health care and its impact on provider and patient … Ask, "Would you see my transplant patient for me? … No one argues about the effect of fatigue on performance and how dangerous that is for patients if health … It used to be about our obligation toward the patient. … A survey of physician and nurse knowledge, attitudes, and practices around injection safety.
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - Patient Safety. WHO Guidelines on Hand Hygiene in Health Care. … safety culture within the institution. … You will realize that from performance monitoring, that education and institutional safety culture have … Regarding the patient position, I completely agree that patients should have the right to benefit from … We have been involving patients in patient participation and/or patient empowerment strategies for some
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psnet.ahrq.gov/node/72563/psn-pdf
December 07, 2020 - medical
doctors to provide infection prophylaxis patients prior to dental visits, such as for patients … I believe that study
was limited to one state, but she did do a national survey of the National Dental … KH: Has anybody looked at what the safety culture is within dental practices and how that correlates … My team randomized a cohort of patients to look at the impact of a brief pre-visit intervention in patients … In this intervention, the patients were instructed on what to expect post
extraction, we provided non-opioid
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psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - After implementation, periodic testing using test patients in the live EHR is necessary.(20) The
second … charts on a single
computer). … Electronic health record-related safety concerns:
a cross-sectional survey. … Analysis of clinical decision support system malfunctions: a
case series and survey. … are lost or incorrectly
transmitted or displayed.(30,31)
Alert for monitoring thyroid function in patients
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - patient safety. … conducted by ISMP targeting directors of pharmacy or their designees, out of 300 respondents, 87% reported … effects on IV therapies for patients.( 8 )
Drug shortages occur for a variety of reasons. … Several strategies can help minimize the effects of drug shortages on patient safety. … Effects on patient care caused by drug shortages: a survey. J Manag Care Pharm. 2013;19:783-788.
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - safety and then devise strategies to minimize the risk to future patients. … A survey of emergency physician and nurse attitudes. … time)
B
Goals, policies, and standards
Probably not a factor
-
Safety … culture and priorities
Reactive culture (eg, address problems only when they occur) - Proactive … April 28, 2021
Distractions in the anesthesia work environment: impact on patient safety
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - This primer focuses on personal health literacy, which is defined as “the
degree to which individuals … The only nationally representative survey of health literacy, conducted in 2003,
tested adults' ability … literacy, 53% had an intermediate level, and only 12% had a proficient
level of health literacy.6 This survey … as most patients will automatically say yes. … In
one study, in-person training on how to use patient portals increased patients’ portal usage and
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - RW: Tell us about the Partnership for Patients. … https://innovation.cms.gov/innovation-models/partnership-for-patients
safety: reducing all-cause patient … The patient
safety movement, Blue Cross Blue Shield? the list goes on and on. … It was an era when some of the early data about patient safety was
somewhat disappointing. … alignment of multiple payment incentives, both for additional funding
and also payment penalties, various survey
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - RW : Tell us about the Partnership for Patients . … But thought of broadly, the Partnership for Patients was much more than HENs. … The patient safety movement, Blue Cross Blue Shield? the list goes on and on. … It was an era when some of the early data about patient safety was somewhat disappointing. … alignment of multiple payment incentives, both for additional funding and also payment penalties, various survey
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - Results From University of Kansas Hospital 11
Improvement in outcomes: The impact of PROMPT on patient … Surveys administered to nurses during the 6 years following initiation also indicated significant improvement … : A randomized controlled trial (RCT) focused on the care of patients with eclampsia found that PROMPT … a 185-question multiple choice questionnaire increasing by an average of 20.6 points. … Increased safety attitude: As measured by Safety Attitude Questionnaire, this same RCT found a significant
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - Another example would be patients on anticoagulation. … It's possible, in certain areas, to prevent 90% of errors and have no impact whatsoever on patients because … Building a safety culture clearly has a big part in enabling people to report problems in the system … November 20, 2019
Comparing NICU teamwork and safety climate across two commonly used survey … August 14, 2018
The correlation between neonatal intensive care unit safety culture and
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psnet.ahrq.gov/node/861882/psn-pdf
January 31, 2024 - the community, and that access might make them more vulnerable to violence, as the
ECRI Institute’s survey … Notably, better communication
between clinicians and patients may reduce patient-reported non-routine … The impact of “To Err Is Human” on patient safety in
anesthesiology. … Patient Safety in Primary Care: Conceptual Meanings to the
Health Care Team and Patients. … on patients’ outcomes.
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - , so another nurse and the respiratory therapist placed the patient on the NRM. … in acute medical wards, the issues surrounding patient safety for transport for non-ICU patients have … ill patients. … Focus initial efforts on the most frequent source units and patient types (ages, clinical diagnoses). … August 17, 2017
Survey of nurses' experiences applying The Joint Commission's medication
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psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
January 01, 2017 - It's about the patient, and such a focus might be a distraction from patient safety. … So you're no longer taking care of four patients; you're sitting on your butt waiting for your back to … Real and lasting progress in improving workplace safety can only be achieved by changing the safety culture … implementing Job Safety Behavioral Observation teams and adopting a robust, repeatable process can improve the safety … culture of the workplace and result in fewer injuries.
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - safety and then devise strategies to minimize the risk to
future patients. … The increasing use of standardized patients is a welcome
addition to health care professional education … A survey of emergency physician and nurse
attitudes. … constraints (could limit staff
training time)
B
Goals, policies, and standards Probably not a factor -
Safety … culture and priorities
Reactive culture (eg, address problems only when they
occur) - Proactive approach
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - Our study looking at data from the National Ambulatory Medical Care Survey showed that 0.5% of all … There is a real need for being able to tailor these interventions on the provider side and on the patient … We talked about safety culture. Then we interviewed him again about a year ago. … And he said he wasn't focusing much on safety culture anymore because people were so burned out that … We really need to work on our patient experience.
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - As the detrimental impact of poorly functioning teams on patient safety has been recognized, it has been … Why does health care depend so much on the experiences of others to improve safety? … A third area would be AHRQ's Hospital Survey on Patient Safety Culture —more and more organizations … We don't just struggle with this in patient safety, we struggle with it on the U.S. … safety program on compensation payments and sentinel events.
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - About 10 minutes later, the nurse returned to check on the patient and found her to be unresponsive and … Patients and families will
often identify patient safety risks that are not detected by other mechanisms … who has been harmed, but also the risk of
harm to future patients. … Patient complaints offer just one window on poor performance and should be considered in the
context … A
national survey of Physician Health Programs. J Subst Abuse Treat. 2009;37:1-7.