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psnet.ahrq.gov/taxonomy/term/3440
April 10, 2025 - Situational Awareness
Situational awareness refers to the degree to which one's perception of a situation matches reality. In the context of crisis management, where the phrase is most often used, situational awareness includes awareness of fatigue and stress among team members (including oneself), environmental thre…
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psnet.ahrq.gov/taxonomy/term/3460
August 11, 2025 - Swiss Cheese Model
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular …
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psnet.ahrq.gov/taxonomy/term/3475
June 09, 2025 - Error
An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome. For instance, ordering a medication for a patient with a documented allergy to that medication would be an act of commission. Failing to pre…
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psnet.ahrq.gov/taxonomy/term/3437
May 23, 2025 - Adverse Event
Any injury caused by medical care. Examples: pneumothorax from central venous catheter placement anaphylaxis to penicillin postoperative wound infection hospital-acquired delirium (or "sundowning") in elderly patients Identifying something as an adverse event does not imply "error," "negligence," or po…
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psnet.ahrq.gov/issue/short-and-long-term-effects-electronic-medication-management-system-paediatric-prescribing
August 28, 2024 - Study
Short- and long-term effects of an electronic medication management system … Short- and long-term effects of an electronic medication management system on paediatric prescribing … This cluster randomized controlled trial examined the short- and long-term impacts of an electronic … researchers observed a decrease in medication errors one year after implementation, suggesting long-term … Short- and long-term effects of an electronic medication management system on paediatric prescribing
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psnet.ahrq.gov/issue/economics-patient-safety-part-iii-long-term-care-valuing-safety-long-haul
September 28, 2022 - Book/Report
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety … Citation Text:
The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long … Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges … This report examined the costs of avoidable problems in long term care and suggests prevention strategies … September 5, 2008
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Long-Term Care
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psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-facilities-r18-0
January 11, 2023 - Grant Announcement
Making Health Care Safer in Ambulatory Care Settings and Long-term … Citation Text:
Making Health Care Safer in Ambulatory Care Settings and Long-term Care Facilities ( … projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term … January 8, 2020
Making Health Care Safer in Ambulatory Care Settings and Long Term Care … January 8, 2020
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Researchers
Long-Term
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psnet.ahrq.gov/issue/infection-control-measure-performance-long-term-care-hospitals-and-their-relationship-joint
June 07, 2023 - Study
Infection control measure performance in long-term care hospitals and their … Infection control measure performance in long-term care hospitals and their relationship to Joint Commission … this analysis compared the incidence of HAIs in Joint Commission-accredited versus non-accredited long-term … October 12, 2022
Long-term care healthcare-associated infections in 2021: an analysis … August 5, 2020
The coronavirus and the risks to the elderly in long-term care.
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psnet.ahrq.gov/issue/patient-outcomes-dose-reduction-or-discontinuation-long-term-opioid-therapy-systematic-review
April 08, 2019 - Classic
Patient outcomes in dose reduction or discontinuation of long-term … Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review … This systematic review included 67 studies involving dose reduction or discontinuation of long-term opioid … Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review … January 11, 2017
The effectiveness and risks of long-term opioid therapy for chronic
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psnet.ahrq.gov/issue/effect-computerized-provider-order-entry-clinical-decision-support-adverse-drug-events-long
February 26, 2009 - computerized provider order entry with clinical decision support on adverse drug events in the long-term … computerized provider order entry with clinical decision support on adverse drug events in the long-term … Adverse drug events (ADEs) are common in the long-term care setting, in part because many residents … effectiveness of a computerized provider order entry (CPOE) system at preventing ADEs in two long-term … computerized provider order entry with clinical decision support on adverse drug events in the long-term
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psnet.ahrq.gov/issue/evaluation-medication-incidents-long-term-care-facility-using-electronic-medication
May 18, 2022 - Study
Evaluation of medication incidents in a long-term care facility using electronic … Evaluation of medication incidents in a long-term care facility using electronic medication administration … This study of medication administration errors was conducted in a Canadian long-term care facility following … Evaluation of medication incidents in a long-term care facility using electronic medication administration … September 9, 2020
For-profit long-term care homes and the risk of COVID-19 outbreaks
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psnet.ahrq.gov/issue/medication-administration-errors-older-people-long-term-residential-care
June 26, 2019 - Study
Medication administration errors for older people in long-term residential … Medication administration errors for older people in long-term residential care. … medication administration (BCMA) system revealed that over a 3-month period, half of the residents of long-term … Medication administration errors for older people in long-term residential care. … 12, 2021
Computerized physician order entry with clinical decision support in long-term
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psnet.ahrq.gov/issue/care-quality-and-safety-long-term-aged-care-settings-systematic-review-and-narrative-analysis
August 17, 2022 - Review
Care quality and safety in long-term aged care settings: a systematic review … Care quality and safety in long‐term aged care settings: a systematic review and narrative analysis of … systematic review including 24 articles evaluated methods for measuring missed nursing care in long-term … Care quality and safety in long‐term aged care settings: a systematic review and narrative analysis of … November 18, 2020
Disclosing and reporting practice errors by nurses in residential long-term
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psnet.ahrq.gov/issue/computerized-clinical-decision-support-during-medication-ordering-long-term-care-residents
February 11, 2009 - Study
Computerized clinical decision support during medication ordering for long-term … Computerized clinical decision support during medication ordering for long-term care residents with renal … computerized provider order entry with clinical decision support on adverse drug events in the long-term … February 11, 2009
Nursing time devoted to medication administration in long-term care … September 27, 2016
The incidence of adverse drug events in two large academic long-term
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psnet.ahrq.gov/issue/nursing-time-devoted-medication-administration-long-term-care-clinical-safety-and-resource
February 11, 2009 - Study
Nursing time devoted to medication administration in long-term care: clinical … Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications … Medication administration in long-term care facilities is a lengthy process, and the large number of … computerized provider order entry with clinical decision support on adverse drug events in the long-term … March 4, 2011
The incidence of adverse drug events in two large academic long-term care
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psnet.ahrq.gov/issue/drive-deprescribe
August 19, 2020 - The Society for Post-Acute and Long-Term Care Medicine. … Linkedin
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June 23, 2021
The Society for Post-Acute and Long-Term … This collective program encourages long-term care organizations, physicians, and pharmacists to take … The Society for Post-Acute and Long-Term Care Medicine. … August 16, 2023
Long-Term Trends of Psychotropic Drug Use in Nursing Homes.
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psnet.ahrq.gov/issue/incidence-adverse-drug-events-two-large-academic-long-term-care-facilities
February 11, 2009 - Study
The incidence of adverse drug events in two large academic long-term care facilities … The incidence of adverse drug events in two large academic long-term care facilities. … Investigators determined the rate of adverse drug events (ADEs) in two academic long-term facilities, … The incidence of adverse drug events in two large academic long-term care facilities. … computerized provider order entry with clinical decision support on adverse drug events in the long-term
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psnet.ahrq.gov/issue/assessing-quality-older-persons-emergency-transitions-between-long-term-and-acute-care
March 17, 2021 - Study
Assessing quality of older persons' emergency transitions between long-term … Assessing quality of older persons’ emergency transitions between long-term and acute care settings: … The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ … process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term … Assessing quality of older persons’ emergency transitions between long-term and acute care settings:
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - Collection
Curated Libraries
Subscribed
Patient and Family Engagement in Long Term … Medication errors are a common cause of preventable harm in long-term care facilities. … Older adults in long-term care settings can be vulnerable to patient safety incidents. … Older adults in long-term care settings can be vulnerable to patient safety incidents. … Medication errors are a common cause of preventable harm in long-term care facilities.
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psnet.ahrq.gov/issue/computerized-physician-order-entry-clinical-decision-support-long-term-care-facilities-costs
March 29, 2010 - Review
Computerized physician order entry with clinical decision support in long-term … Computerized physician order entry with clinical decision support in long-term care facilities: costs … In analyzing barriers that prevent broad use of computerized physician order entry (CPOE) in long-term … Computerized physician order entry with clinical decision support in long-term care facilities: costs … December 22, 2010
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Long-Term Care