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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/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/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/insensible-losses-when-medical-community-forgets-family
January 17, 2024 - A systematic review and meta-analysis.
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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/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/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/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/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/issue/technical-evaluation-testing-and-validation-usability-electronic-health-records-empirically
March 01, 2017 - December 9, 2020
Artificial intelligence versus clinicians: systematic review of design
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psnet.ahrq.gov/issue/development-professionalism-committee-approach-address-unprofessional-medical-staff-behavior
October 19, 2022 - Edwin Boudreaux about Suicide Prevention
March 24, 2025
Rooting an error review … July 28, 2014
Implementing a systematic response to medication errors.
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psnet.ahrq.gov/issue/interventions-health-organisations-reduce-impact-adverse-events-second-and-third-victims
October 11, 2017 - The influence of context on the effectiveness of hospital quality improvement strategies: a review … of systematic reviews.
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psnet.ahrq.gov/issue/using-consumer-based-kiosk-technology-improve-and-standardize-medication-reconciliation
August 23, 2023 - 2008
Interventions promoting employee "speaking-up" within healthcare workplaces: a systematic … narrative review of the international literature.
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psnet.ahrq.gov/issue/standardising-classification-harm-associated-medication-errors-harm-associated-medication
August 28, 2024 - A systematic review and meta-analysis.
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psnet.ahrq.gov/issue/prevention-pediatric-medication-errors-hospital-pharmacists-and-potential-benefit
December 15, 2011 - November 25, 2009
Effects of health information technology on patient outcomes: a systematic … review.
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psnet.ahrq.gov/issue/reporting-improving-how-root-cause-analysis-teams-shape-patient-safety-culture
July 31, 2024 - A systematic review and meta-analysis.
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psnet.ahrq.gov/issue/development-core-drug-list-towards-improving-prescribing-education-and-reducing-errors-uk
April 13, 2022 - April 29, 2018
Hospitalizations and deaths related to adverse drug events worldwide: systematic … review of studies with national coverage.
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psnet.ahrq.gov/issue/serious-adverse-drug-events-reported-fda-analysis-fda-adverse-event-reporting-system-2006
December 15, 2010 - 15, 2010
The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic … review for a National Institutes of Health Pathways to Prevention Workshop.