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psnet.ahrq.gov/issue/team-training-program-using-human-factors-enhance-patient-safety
January 24, 2024 - This article provides background on a crew resource management training initiative as well as an overview … of survey results from five surgical facilities that participated in the program. … July 26, 2023
Frequency of failure to inform patients of clinically significant outpatient … January 19, 2011
Safeguarding patients: complexity science, high reliability organizations … Adherence to a medication safety protocol: current practice for labeling medications and solutions on
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psnet.ahrq.gov/issue/role-relatives-ethnic-minority-patients-patient-safety-hospital-care-qualitative-study
March 15, 2016 - Study
Role of relatives of ethnic minority patients in patient safety in hospital … Role of relatives of ethnic minority patients in patient safety in hospital care: a qualitative study … Role of relatives of ethnic minority patients in patient safety in hospital care: a qualitative study … August 21, 2014
Design of a retrospective patient record study on the occurrence of adverse … March 23, 2012
French national survey of inpatient adverse events prospectively assessed
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - electronic reporting interfaces, excluding reported
information from performance reviews, improving safety … culture, and focusing on errors rather than adverse
events. … only 13 US reporting systems for which publications described a feedback mechanism.(17) A
national survey … The senior
leadership defines what the safety culture should look like, seeks out new safety technologies … Adverse-event-reporting practices by US hospitals: results
of a national survey.
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - The impact of advance care planning on end of life care in elderly patients: randomized controlled trial … The development and validation of a questionnaire to audit advance care planning. … a multicentre survey. … multicenter survey of clinicians. … November 21, 2016
Organizational and safety culture in Canadian intensive care units:
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psnet.ahrq.gov/issue/important-actions-community-pharmacists-need-take-now-reduce-potentially-harmful-dispensing
June 30, 2021 - This webinar focused on high-alert medications and discuss unreliable medication delivery methods. … June 10, 2018
Failure to cap IV tubing and disinfect IV ports place patients at risk … , 2018
ISMP updates its list of drug names with tall man (mixed case) letters based on … survey results. … March 16, 2025
The Impact of Artificial Intelligence (AI) on the Safety of Patients.
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digital.ahrq.gov/sites/default/files/docs/hit-cdm-slides-062111.pdf
June 21, 2011 - Surgeon General’s 2000 Report on Oral Health in
America and the 1995 Institute of Medicine Report on … Follow-up P (paired t-
test)
4.1 ± .54 4.3 ± .65 .17
3.8 ± .60 4.5 ± .52 .01*
N=11
Source: Provider
Surveys … March
2008 and March
2010
Satisfaction with CDS
Components
N=18
Source: Provider Surveys March … If the patient has
multiple problems, [it asks for] too
many details. . .”
“. . . … ) did not
have paper-based comparators
– Widely cited negative studies use inadequate and
dated survey
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psnet.ahrq.gov/node/39294/psn-pdf
January 03, 2017 - Patient handoffs: standardized and reliable measurement
tools remain elusive. … Patient handoffs: standardized and reliable measurement tools remain elusive. … Jt
Comm J Qual Patient Saf. 2010;36(2):52-61. … https://psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-measurement-tools-remain-elusive … https://psnet.ahrq.gov/issue/improving-hand-communication
https://psnet.ahrq.gov/issue/handoffs-causing-patient-harm-survey-medical-and-surgical-house-staff
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psnet.ahrq.gov/issue/preferences-and-perceptions-medical-error-disclosure-among-marginalized-populations-narrative
June 15, 2022 - Jt Comm J Qual Patient Saf . 2022; 48 (10) :539-548 . … August 12, 2020
Development and validation of a brief culture-of-safety survey. … 2021
Physician task load and the risk of burnout among US physicians in a national survey … July 7, 2021
Impact of providing patients access to electronic health records on quality … July 8, 2020
The views and experiences of patients and health-care professionals on the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
May 05, 2008 - Qualitative
data, including feedback from health care providers and patients on the value and concerns … When simulations typically occur in empty patient rooms, these
rooms might be occupied by actual patients … organization, State law, safety culture, and other local factors. … But it is not traditional “human subject research” on patients, of the kind the
Federal Common Rule … Between these two extremes of classical clinical
research on informed patients and pure employee mandatory
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www.ahrq.gov/patient-safety/settings/hospital/resource/about.html
December 01, 2017 - Sign up: CAHPS Database - Hospital Component Email updates
Sign up: Hospital Survey on Patient … Safety Culture Email updates
Sign up: HCUP Highlights Email updates
Emergency Severity Index … Guide to Patient and Family Engagement in Hospital Quality and Safety
Research shows that when patients … Readmissions are a significant issue among patients with Medicaid. … Improving Patient Safety Systems for Patients with Limited English Proficiency
This TeamSTEPPS guide
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/046-evidence-behind-decolonization-strategies-slides.pptx
October 01, 2024 - of VRE
Results: Compared with soap and water, bathing with CHG led to decrease in VRE on patient skin … and 282,803 ICU patient-days
Arm 1: Routine Care
All patients screened
Contact precautions for known … mupirocin resistance in trial29
CLABSI benefit seen with rapid adoption in 95 other hospitals30
Per a 2021 survey … Patient Educational Resources
Resources and instructions to educate patients about decolonization. … Access the one-pager on the 4 Es here.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module6/facilitator-notes.docx
March 01, 2017 - learned from examples of success across multiple settings
SLIDE 2
SAY:
What is sustainability in the patient … Lastly, sustainability engages staff to create a safety culture that lasts beyond the life of the project … Both are necessary for successful safety culture change throughout an organization. … This team will ideally include—
· Facility team lead
· Administrator
· Data coordinator
· Survey coordinator … and quality improvement data, and on how to use the data system.
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psnet.ahrq.gov/issue/implementing-pediatric-surgical-safety-checklist-or-and-beyond
March 09, 2016 - February 21, 2024
Preventing patient harm via adverse event review: An APSA survey regarding … September 29, 2017
Patients count on it: an initiative to reduce incorrect counts and … February 3, 2021
Engaging the patient and family in the surgical safety process utilizing
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psnet.ahrq.gov/issue/medication-errors-involving-healthcare-students
December 19, 2016 - PA-PSRS Patient Saf Advis. March 2016;13:18-23. … PA-PSRS Patient Saf Advis. March 2016;13:18-23. … in senior pharmacy students using the innovative "Horror Room" simulation setting: a cross-sectional survey … April 26, 2023
Special Issue on Medication Safety. … July 31, 2019
Patient Safety.
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psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections
June 10, 2018 - Author(s)
Raising the index of suspicion: red flags that represent credible threats to patient … , 2018
ISMP updates its list of drug names with tall man (mixed case) letters based on … survey results. … May 7, 2018
Pump up the volume: tips for increasing error reporting and decreasing patient … July 5, 2013
Effects of technological interventions on the safety of a medication-use
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - on call. … Second, they have at least some training in critical care, and many of these patients require lengthy … And fourth, data have shown that NSTI outcomes are improved when patients are managed by an experienced … Symons et al. summarized these concerns nicely in their survey of subspecialty surgeons: “while EGS surgeons … surgeons, subspecialty surgeons and the future management of emergency surgery: results of a national survey
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psnet.ahrq.gov/issue/delivering-right-diet-right-patient-every-time
March 27, 2018 - This article analyzed data on dietary errors submitted to a state reporting program and found that … more than 60% of patients received trays containing food items to which they were allergic. … January 20, 2016
Medication errors affecting pediatric patients: unique challenges for … October 7, 2015
Wrong-site orthopedic operations on the extremities: the Pennsylvania … April 17, 2017
View More
Related Resources
Survey results reveal
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psnet.ahrq.gov/issue/improving-patient-safety-medicine-model-anaesthesia-care-enough
June 08, 2010 - safety in surgical patients. … March 4, 2020
Evaluation of the culture of safety: survey of clinicians and managers … February 15, 2023
Impact of the World Health Organization surgical safety checklist on … patient safety. … May 27, 2009
The influence of standardisation and task load on team coordination patterns
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psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
October 04, 2017 - Open and honest discussion with patients after an error or near miss is key to effective disclosure … September 30, 2020
National Training Survey 2013: Concerns about Patient Safety. … March 4, 2010
Technical patient safety solutions for medicines reconciliation on admission … December 9, 2020
Impact of providing patients access to electronic health records on … June 12, 2019
Canadian Disclosure Guidelines: Being Open and Honest with Patients and
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/ssi-investigation-slides.html
December 01, 2017 - Slide 3: Readiness Bridge
Have you–
Educated frontline on the program goals? … Completed safety culture survey (HSOPS)? … Depends on your local SSI prevention bundle. … Example: percentage of patients receiving appropriate antibiotic redosing. … Outcome Data
What happens to patients.