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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - psnet.ahrq.gov/primer/diagnostic-errors
https://psnet.ahrq.gov/issue/diagnostic-errors-emergency-department-systematic-review … Criteria for pediatric sepsis-a systematic review and meta-
analysis by the Pediatric Sepsis Definition … Hyponatremia in infectious diseases-a literature
review. … review. … Dual-process cognitive interventions to enhance diagnostic
reasoning: a systematic review.
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Moving upstream: a review of the evidence of the impact of
outpatient palliative care.? … review and meta-analysis.? … The health care cost of palliative care for cancer patients: a
systematic review.? … A systematic review of factors influencing older adults' decision
to accept or decline cancer treatment … Unmet care needs of advanced cancer patients and
their informal caregivers: a systematic review.?
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - Criteria for pediatric sepsis-a systematic review and meta-analysis by the Pediatric Sepsis Definition … Hyponatremia in infectious diseases-a literature review. … review. … Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. … review and meta-analysis.
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Laboratory Medicine Best Practices Workgroup has made recommendations for
limiting hemolysis based on a systematic … review and meta-analysis of the literature (Table).(6,7) The
strongest evidence-based recommendation … Effectiveness of practices to reduce blood sample hemolysis in
EDs: a laboratory medicine best practices systematic … review and meta-analysis.
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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - crises.1
The I-READI acronym outlines the steps (i.e., Integration, Root-Cause Analysis, Evidence Review … innovation also requires that team members have skills and experience with aggregate root-cause
analysis to review … systems to monitor care delivery, quality, and safety metrics in real time
Daily board rounds with review … of real-time patient data and systematic patient safety checklists
Ability to convene emergency meetings … Strategies for monitoring and updating clinical
practice guidelines: a systematic review.
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Key themes are highlighted in the following sections of this Year in Review. … Organizations can adopt a systematic approach to gather and analyze data, identify system failures, … Systematic review of burnout in U.S. nurses. Nurs Clin North Am. 2022;57(1):1-20 .
5. … A systematic review and scoping reviews.
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psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
December 23, 2020 - review and meta-analysis. … Models of non-hospice palliative care: a review. … The health care cost of palliative care for cancer patients: a systematic review. … A systematic review of factors influencing older adults' decision to accept or decline cancer treatment … Unmet care needs of advanced cancer patients and their informal caregivers: a systematic review.
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - illness
• Categorize systemic anticoagulation as a high-risk clinical
situation
• Choose and apply systematic … herniation
• Patient was placed on comfort care and later died
Case Details
8
• During the post-mortem review … despite lack of supporting evidence or evidence to the contrary
• In this case, the clinician did not review … Safety and
Systems Change Needed
19
20
Approach to Improving Safety
• Hospitals should adopt systematic … The use of cognitive aids during emergencies in anesthesia: a review of the literature.
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - The barriers and enhancers to trust in a just culture in hospital settings: a systematic … review. … Assessment of fidelity in interventions to improve hand hygiene of healthcare workers: a systematic … review.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Intern Med. 2012;157:49-58. http://www.ncbi.nlm.nih.gov/pubmed/22751760
Disseminating the Guidelines
A systematic … review of interventions to reduce inappropriate transfusions showed that the following are effective … Reducing the amount of blood transfused: a systematic review of behavioral interventions to change physicians
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - should attend to laboratory results and radiological reports prior to releasing them to patients for review … The impact of eHealth on the quality and safety of health care: a systematic overview. … Impact of electronic medical record on physician practice in office settings: a systematic review. … electronic medical records on patient–doctor communication during consultation: a narrative literature review … Reserve templates for documentation Separate some data entry from the encounter; review
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psnet.ahrq.gov/issue/what-has-airbus-a380-captain-got-do-omfs-lessons-aviation-improve-patient-safety
October 04, 2023 - February 15, 2017
Teamwork, communication and safety climate: a systematic review of
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psnet.ahrq.gov/issue/analysis-deaths-related-anesthesia-period-1996-2004-closed-claims-registered-danish-patient
November 13, 2024 - November 21, 2021
Identifying high-risk medication: a systematic literature review.
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psnet.ahrq.gov/issue/causes-errors-electrocardiographic-diagnosis-atrial-fibrillation-physicians
April 16, 2018 - April 16, 2018
Organizational resilience as paradox management: a systematic review of
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psnet.ahrq.gov/issue/safer-healthcare-home-detecting-correcting-and-learning-incidents-involving-infusion-devices
October 18, 2018 - Patients' experiences and perspectives of patient-reported outcome measures in clinical care: a systematic … review and qualitative meta-synthesis.
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psnet.ahrq.gov/issue/medical-error-disclosure-training-evidence-values-based-ethical-environments
October 15, 2016 - A systematic review of the literature.
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psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-family
January 17, 2024 - A systematic review and meta-analysis.
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psnet.ahrq.gov/issue/addressing-opioid-epidemic-united-states-lessons-department-veterans-affairs
September 07, 2022 - Clinicians' expectations of the benefits and harms of treatments, screening, and tests: a systematic … review.
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psnet.ahrq.gov/issue/recommendations-national-panel-quality-improvement-obstetrics
July 12, 2023 - Author(s)
Identifying a list of healthcare 'never events' to effect system change: a systematic … review and narrative synthesis.
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psnet.ahrq.gov/issue/use-emergency-manual-during-intraoperative-cardiac-arrest-interprofessional-team-positive
April 03, 2019 - June 16, 2011
Simulation exercises as a patient safety strategy: a systematic review.