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psnet.ahrq.gov/issue/safety-care-caregivers-cancer-patients
March 02, 2012 - Safety of Care by Caregivers of Cancer Patients. … Cancer patients often rely on family members or paid caregivers to assist with care maintenance at … Safety of Care by Caregivers of Cancer Patients. … computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey … October 19, 2011
Improving Patient Safety.
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www.ahrq.gov/news/newsletters/e-newsletter/947.html
February 01, 2025 - (Source: AHRQ Medical Expenditure Panel Survey Statistical Brief #558, Lack of Reliable Transportation … Some interventions—like patient portals, care for complex patients and electronic health records—had … Researchers noted healthcare leaders can focus on implementing the identified strategies to improve patient-centered … cover AI’s potential to enhance clinician productivity, improve quality of care and increase patients … use and evaluate AHRQ resources including Calibrate Dx , Measure Dx and the Toolkit for Engaging Patients
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psnet.ahrq.gov/issue/expand-evidence-base-about-harms-tests-and-treatments
May 19, 2021 - Research is especially important in vulnerable patient populations. … Leveraging a safety event management system to improve organizational learning and safety … culture. … Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey … on United States operating rooms.
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psnet.ahrq.gov/issue/agreement-expert-judgment-causality-assessment-adverse-drug-reactions
November 29, 2023 - October 19, 2022
Priorities for pediatric patient safety research. … June 22, 2009
Effect of a postdischarge virtual ward on readmission or death for high-risk … patients: a randomized clinical trial. … October 4, 2011
Adverse drug event reporting in intensive care units: a survey of current … June 22, 2009
Detecting adverse drug reactions on paediatric wards: intensified surveillance
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psnet.ahrq.gov/issue/financial-incentives-and-mortality-taking-pay-performance-step-too-far
December 21, 2017 - December 21, 2017
Development of a high-value care culture survey: a modified Delphi … January 1, 2022
Five strategies for how patients and families can improve patient safety … : World Patient Safety Day 2023. … October 4, 2023
Multispecialty physician online survey reveals that burnout related to … August 1, 2023
Combined impact of Medicare's hospital pay for performance programs on
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psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
May 08, 2024 - The authors recommend a national database specific to periprocedural falls and offer suggestions on … May 8, 2024
Seven features of safety in maternity units: a framework based on multisite … cross-sectional survey. … Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey … on United States operating rooms.
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psnet.ahrq.gov/issue/using-claims-data-based-sentinel-system-improve-compliance-clinical-guidelines-results
October 19, 2022 - October 19, 2022
Evaluation of clinical practice guidelines on fall prevention and management … January 25, 2016
Hospital ward adaptation during the COVID-19 pandemic: a national survey … Improving Diagnostic Safety and Quality
April 26, 2023
Perspectives on … May 27, 2011
The impact of computerized provider order entry on medication errors in … Addition of electronic prescription transmission to computerized prescriber order entry: effect on
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - should be equipped for pelvic examinations
so that clinicians do not rely on CT to evaluate patients … a unit that does not normally
care for postpartum or postoperative gynecology patients. … Using a standardized method to identify patients with vaginal packing. … The when and how of the gynaecological examination: a
survey among Norwegian general practitioners. … A survey of physical examination skills taught in undergraduate nursing programs: are we teaching too
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psnet.ahrq.gov/issue/association-between-clinic-opioid-administration-and-discharge-opioid-prescription-urgent
May 19, 2021 - Opioid use is an ongoing patient safety concern. … Related Resources From the Same Author(s)
Influence of opioid prescription policy on … opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey … September 1, 2021
Association of implementation and social network factors with patient … safety culture in medical homes: a coincidence analysis.
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psnet.ahrq.gov/issue/cusp-stop-bsi-evaluating-relationship-between-central-line-associated-bloodstream-infection
January 30, 2013 - Study
On the CUSP: Stop BSI: evaluating the relationship between central line–associated … rate and patient safety climate profile. … This study determined that results from the AHRQ Hospital Survey on Patient Safety were associated … These results argue for integrating survey results rather than testing whether each separate aspect of … rate and patient safety climate profile.
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psnet.ahrq.gov/issue/multiple-institution-comparison-resident-and-faculty-perceptions-burnout-and-depression
October 19, 2022 - Physician burnout is widespread and may adversely affect patient safety . … This cross-sectional survey study of surgery residents and attendings across 6 general surgery training … Citation
Related Resources From the Same Author(s)
Optimizing Pediatric Patient … diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient … July 15, 2020
Effect on patient safety of a resident physician schedule without 24-hour
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digital.ahrq.gov/sites/default/files/docs/cds-slides-10192021.pdf
October 19, 2021 - Centered View-Focus on
Communication
*Simulated Patient
23
Cognitive Support – Temporal Analysis … current status
► Different patients having different signs/thresholds
► Focusing only on clinical indicators … Set-up of local quality improvement team
► Adaptation of interview-based work system assessment to survey-based … 2.0: a human factors framework for studying
and improving the work of healthcare professionals and patients … task, debriefing survey
77
78
79
Crossover
• Same case: conventional,
composable
• Juxtaposition
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
February 01, 2017 - safety culture. … To improve and maintain a positive patient safety culture, ensure that problems are not only fixed for … Second-order problem solving addresses future needs and improves overall patient safety culture. … Only then can you progress to second-order problem solving to improve the long-term patient safety culture … Recognizing the defects hindering a strong patient safety culture is the first step to building a culture
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www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
January 01, 2024 - Evaluation Surveys. … The survey instruments used a five-point Likert scale to measure the respondents’
agreement or disagreement … Patient Survey Instrument Results
During a 4-week period in April and May 2012, 267 patients from the … Two percent (four patients) of respondents said they
did not intend to read the handout, citing prior … Post-Utilization Evaluation Survey
Analysis of the post-utilization surveys suggest that leaders and
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psnet.ahrq.gov/issue/assessing-frequency-and-risk-weight-entry-errors-pediatrics
December 21, 2018 - Weight-based medication dosing can lead to medication errors in pediatric patients . … These findings suggest that a weight-entry trigger tool can identify pediatric patients at risk for … October 4, 2011
Influence of organizational climate and clinician morale on seclusion … English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey … March 18, 2010
The impact of electronic medical records data sources on an adverse drug
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psnet.ahrq.gov/issue/methods-assessing-preventability-adverse-drug-events-systematic-review
July 24, 2013 - However, there is a paucity of evidence on the validity of these instruments, and many do not appear … adverse drug events: a population-based cross-sectional survey. … July 24, 2013
A survey of pharmacists' perception of the work environment and patient … October 11, 2023
Seven features of safety in maternity units: a framework based on multisite … July 1, 2013
The safety implications of missed test results for hospitalised patients
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psnet.ahrq.gov/issue/diagnostic-errors-lead-inappropriate-antimicrobial-use
October 19, 2022 - study found that unnecessary antibiotic use was often a result of diagnostic error , particularly in patients … February 14, 2024
Effect of hospital follow-up appointment on clinical event outcomes … December 21, 2014
Effect of genetic diagnosis on patients with previously undiagnosed … September 9, 2020
Cascades of care after incidental findings in a US national survey … November 6, 2019
The War on Error: Common Diagnostic Errors.
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psnet.ahrq.gov/issue/learning-best
February 22, 2023 - June 28, 2010
Patient safety records: silent witness. … of countermeasures and avoidance strategies by certified registered nurse anesthetists: a national survey … July 27, 2022
Clinical diagnoses vs. autopsy findings in early deceased septic patients … July 13, 2022
Influence of organizational climate and clinician morale on seclusion and … survey study among healthcare staff.
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psnet.ahrq.gov/issue/road-map-advancing-practice-respect-health-care-results-interdisciplinary-modified-delphi
August 01, 2018 - have focused on studying and preventing emotional harm. … accountability, partnering with patients , and supporting frontline staff. … November 30, 2018
The "Seven Pillars" response to patient safety incidents: effects on … March 20, 2015
The interpretability of doctor identification badges in UK hospitals: a survey … of nurses and patients.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
December 01, 2017 - Both safety culture and technical interventions must be managed to sustain progress. … culture with HSOPS survey
ADAPTIVE WORK
Comprehensive Unit-based Safety Program (CUSP)
LOCAL PROBLEMS … culture rather than checklist alone13
Surgical units with strong safety culture yielded significant … But an organization with a relatively poor safety culture saw minimal improvement from the checklist … culture with time and commitment
Foster safety culture growth
Practice and expect open communication