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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - electronic reporting interfaces, excluding reported information from performance reviews, improving safety … culture, and focusing on errors rather than adverse events. … 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. … January 6, 2010
Building a Culture of Patient Safety: Report of the Commission on Patient
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psnet.ahrq.gov/issue/prevalence-copied-information-attendings-and-residents-critical-care-progress-notes
September 28, 2017 - standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey … September 23, 2020
Preventing harm in the ICU—building a culture of safety and engaging patients … May 31, 2023
Patient harm and institutional avoidability of out-of-hours discharge from … March 23, 2022
Investigating the impact of intensive care unit interruptions on patient … July 24, 2019
Data omission by physician trainees on ICU rounds.
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psnet.ahrq.gov/issue/passing-baton-grounded-practical-theory-handoff-communication-between-multidisciplinary
November 16, 2022 - March 31, 2010
Patient outcomes in dose reduction or discontinuation of long-term opioid … Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient … June 3, 2020
Impact of the communication and patient hand-off tool SBAR on patient safety … January 3, 2017
Transfers of patient care between house staff on internal medicine wards … : a national survey.
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psnet.ahrq.gov/issue/intercepting-wrong-patient-orders-computerized-provider-order-entry-system
May 29, 2019 - Effect of restriction of the number of concurrently open records in an electronic health record on … September 4, 2019
The role of housestaff in implementing medication reconciliation on … December 27, 2014
A national survey assessing the number of records allowed open in electronic … July 9, 2018
Engaging hospital patients in the medication reconciliation process using … May 29, 2019
Effect of number of open charts on intercepted wrong-patient medication
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psnet.ahrq.gov/issue/time-trends-pulmonary-embolism-united-states-evidence-overdiagnosis
February 18, 2011 - ' perceptions of "unnecessary" tests and referrals: a national survey of Medicare beneficiaries. … Administration and patients in a national sample. … Resources
Using community detection techniques to identify themes in COVID-19-related patient … September 24, 2017
Do telephone call interruptions have an impact on radiology resident … way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - Shojania is a leading expert on evidence-based patient safety strategies and translating research into … electronic reporting interfaces, excluding reported information from performance reviews, improving safety … culture, and focusing on errors rather than adverse events. … 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/print/pdf/node/73848
July 01, 2022 - unit-based safety program (CUSP) to improve safety culture and perinatal care processes
in 15 Michigan … This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. … A vital component of engaging patients in safety is eliciting their perspective on how they experience … This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. … unit-based safety program (CUSP) to improve safety culture and perinatal care processes
in 15 Michigan
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psnet.ahrq.gov/issue/impact-sars-cov-2-hospital-acquired-infection-rates-united-states-predictions-and-early
August 15, 2012 - Study
Impact of SARS-CoV-2 on hospital acquired infection rates in the United States … December 16, 2020
The psychological experience of obstetric patients and health care … February 7, 2022
View More
Related Resources
Patient … June 9, 2021
Flow accuracy of IV smart pumps outside of patient rooms during COVID-19 … September 23, 2020
Hospital ward adaptation during the COVID-19 pandemic: a national survey
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psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
August 16, 2023 - August 16, 2023
Issues and complexities in safety culture assessment in healthcare. … December 13, 2023
Improving patient safety governance and systems through learning from … successes and failures: qualitative surveys and interviews with international experts. … December 6, 2023
A mixed-methods analysis of patient safety incidents involving opioid … October 21, 2020
Is one-pen, one-patient achievable in the hospital?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/5-red-light-green-light.docx
June 01, 2023 - pathways have the potential to reduce complications, hospital stays, and costs while improving the patient … Common Barriers to ISCR Implementation:
· Resistance to change by both perioperative staff and patients … strong multidisciplinary team with good lines of communication throughout planning and implementation
· Patient … of protocol elements within a hospital (e.g., standardized order set)
· Piloting with small group of patients … Survey of provider perceptions of enhanced recovery after surgery and perioperative surgical home protocols
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psnet.ahrq.gov/issue/identification-doctors-risk-recurrent-complaints-national-study-healthcare-complaints
September 07, 2011 - Although most patient safety efforts focus on identifying and addressing flawed systems, individual clinicians … May 28, 2014
Accountability sought by patients following adverse events from medical … July 28, 2014
Patients do not always complain when they are dissatisfied: implications … November 8, 2013
Distractions and their impact on patient safety. … March 23, 2011
Measurement for improvement: a survey of current practice in Australian
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www.ahrq.gov/sites/default/files/2024-01/nembhard-report.pdf
January 01, 2024 - Our classifications were based on a
qualitative evaluation of the extent to which respondents attributed … Approximately 10-12 months after
answering the baseline survey (February 2008-June 2008), they were … Thus, the survey completion process was expected to
involve multiple knowledgeable respondents even … This factor was assessed using survey respondents’ reported level of
agreement with three survey items … hospitals’ own reports about their behavior submitted via a
single survey/respondent) are the same
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/035-importance-mrsa-prevention-notes.docx
October 01, 2024 - patient safety goal. … MRSA from the environment or on colonized and infected patients can be transmitted to other patients … One national survey estimated that around 7 percent of patients already harbor MRSA at the time of their … Slide 12
Sources of MRSA: Patient Care Environments
SAY:
MRSA can be transmitted through the patient … MRSA can still be spread from colonized patients to others, even if the colonized patient is asymptomatic
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015196-crandall-final-report-2007.pdf
January 01, 2007 - The instrument assesses respondents’ perceptions related to communication changes,
changes in selected … Super user survey tool. … The survey items asked
Super Users about the time they spent on their activities and their attitudes … Thus the patient-
centered clinical workflows for various types of patients provided the interdisciplinary … It avoids duplicate
and wasted efforts on the part of a care team working with patients and families
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psnet.ahrq.gov/issue/adverse-event-protocol-interventional-pain-medicine-importance-organized-response
January 12, 2022 - Related Resources From the Same Author(s)
Evaluation of clinical practice guidelines on … September 23, 2020
Safety considerations in learning new procedures: a survey of surgeons … October 18, 2023
Radiographers' experience of preventing patient safety incidents in … March 1, 2023
Identifying patients whose symptoms are underrecognized during treatment
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www.ahrq.gov/sites/default/files/2024-01/lapane-report.pdf
January 01, 2024 - the survey packet to nonrespondents to the initial
survey, and a final reminder postcard. … The respondents
were asked not to complete the survey at work. … Study Testing GRAM™’s Effectiveness on Patient Safety Begins. … Nurses' and nursing assistants' perceptions of patient safety culture in
nursing homes. … Impact of distribution method on response rates to a
patient safety questionnaire in nursing homes (
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psnet.ahrq.gov/issue/investigating-hospital-supervision-case-study-regulatory-inspectors-roles-potential-co
September 23, 2020 - J Patient Saf. 2021;17(2):122-130. doi:10.1097/pts.0000000000000814. … J Patient Saf. 2021;17(2):122-130. doi:10.1097/pts.0000000000000814. … May 19, 2018
The patients' perspective: hematological cancer patients' experiences of … on healthcare quality? … A survey study.
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psnet.ahrq.gov/issue/implementation-strategy-multicenter-pediatric-rapid-response-system-ontario
September 09, 2015 - The Joint Commission Journal on Quality and Patient Safety. 2016;36(6). doi:10.1016/s1553-7250(10)36041 … The Joint Commission Journal on Quality and Patient Safety . 2016; 36 (6) . … The Joint Commission Journal on Quality and Patient Safety. 2016;36(6). doi:10.1016/s1553-7250(10)36041 … June 19, 2012
Findings of the first consensus conference on medical emergency teams. … February 1, 2011
A survey of nurses' beliefs about the medical emergency team system
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www.ahrq.gov/patient-safety/reports/engage/appf.html
March 01, 2017 - Patient safety culture in primary care: developing a theoretical framework for practical use
Yes … No
Moderate
Evidence synthesis with recommendations for improving safety culture. … New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly … Using digital technology to engage and communicate with patients: a survey of patient attitudes … Yes
Yes
Moderate
Survey methods used to estimate patients interest in using technology
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psnet.ahrq.gov/issue/managing-medication-errors-qualitative-study
December 06, 2023 - November 13, 2024
Defining the incidence of cardiorespiratory instability in patients … July 2, 2019
Effect of genetic diagnosis on patients with previously undiagnosed disease … January 18, 2023
Understanding the peer, manager, and system influence on patient safety … Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey … Creating highly reliable health care: how reliability-enhancing work practices affect patient