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  1. Workaround | PSNet

    psnet.ahrq.gov/taxonomy/term/3504
    June 24, 2025 - Workaround From the perspective of frontline personnel trying to accomplish their work, the design of equipment or the policies governing work tasks can seem counterproductive. When frontline personnel adopt consistent patterns of work or ways of bypassing safety features of medical equipment, these patterns and acti…

  2. Situational Awareness | PSNet

    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…

  3. Swiss Cheese Model | PSNet

    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 …

  4. Error | PSNet

    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…

  5. Adverse Event | PSNet

    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…

  6. Resources | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/quality/tools/cauti-ltc/resources.html
    March 01, 2017 - Resources Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities This section … Implementation: Guide to Implementing a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term … Sustainability: Guide to Sustaining a Program To Reduce Catheter-Associated Urinary Tract Infections in Long-Term … A Unit Guide To Infection Prevention for Long-Term Care Staff ( PDF , 2.97 MB) This guide provides

  7. The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul. | PSNet

    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 View More See More About The Topic Long-Term Care

  8. Making Health Care Safer in Ambulatory Care Settings and Long-term Care Facilities (R18). | PSNet

    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 View More See More About The Topic Researchers Long-Term

  9. Infection control measure performance in long-term care hospitals and their relationship to Joint Commission accreditation. | PSNet

    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.

  10. Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. | PSNet

    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

  11. Venous Thromboembolism | CDS Connect

    cds.ahrq.gov/taxonomy/term/134651
    February 16, 2024 - Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates

  12. Pulmonary Embolism | CDS Connect

    cds.ahrq.gov/taxonomy/term/77441
    February 16, 2024 - Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates

  13. Upper Extremity Deep Vein Thrombosis | CDS Connect

    cds.ahrq.gov/taxonomy/term/138156
    February 16, 2024 - Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates

  14. Venous Thrombosis | CDS Connect

    cds.ahrq.gov/taxonomy/term/55271
    February 16, 2024 - Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates

  15. Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting. | PSNet

    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

  16. Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology. | PSNet

    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

  17. Medication administration errors for older people in long-term residential care. | PSNet

    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

  18. Care quality and safety in long-term aged care settings: a systematic review and narrative analysis of missed care measurements. | PSNet

    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

  19. Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency. | PSNet

    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

  20. Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications. | PSNet

    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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