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Fixing a broken EHR: HIM working in the spotlight to solve common EHR issues. | PSNet

psnet.ahrq.gov/issue/fixing-broken-ehr-him-working-spotlight-solve-common-ehr-issues

March 30, 2016 - Citation Text: Fixing a broken EHR: HIM working in the spotlight to solve common EHR issues. … View more articles from the same authors. … April 15, 2009 How real-time data can change the patient safety game. … : the experience of the onco-haematology center of Tor Vergata Hospital in Rome. … improve the safety and reliability of their own care.

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety. | PSNet

psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety

December 24, 2007 - Created in 2001 to institute changes in health care across the United Kingdom, the National Patient … The two-part report begins with a general discussion of incident reporting , the basis for a national … reporting system, and the development of the Patient Safety Observatory. … The second part builds on this framework by discussing how the acquired data can be used and translated … Copy Citation Related Resources From the Same Author(s) Safer Care for the

Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation. | PSNet

psnet.ahrq.gov/issue/hospital-experiences-using-electronic-health-records-support-medication-reconciliation

August 08, 2014 - View more articles from the same authors. … August 8, 2014 The Patient Safety Initiative at America’s Public Hospitals: The Year … February 9, 2011 Using Telehealth to Improve Quality and Safety: Findings from the AHRQ … September 1, 2016 The problem with medication reconciliation. … good, the bad, and the improvements.

Contributions by the Agency for Healthcare Research and Quality and Grantees. | PSNet

psnet.ahrq.gov/issue/contributions-agency-healthcare-research-and-quality-and-grantees

July 29, 2010 - View more articles from the same authors. … This special series of articles highlights the progress and current state of patient safety since the … The series was developed by the Agency for Healthcare Research and Quality (AHRQ) as a method to critically … power of multidisciplinary teams, realizing the benefits of information technology , and approaching … every issue through the patient's eyes .

The frustrating case of incident-reporting systems. | PSNet

psnet.ahrq.gov/issue/frustrating-case-incident-reporting-systems

June 22, 2022 - The frustrating case of incident-reporting systems. … View more articles from the same authors. … The frustrating case of incident-reporting systems. … June 22, 2022 Expanding the scope of Critical Care Rapid Response Teams: a feasible approach … January 31, 2024 Vulnerability of the medical product supply chain: the wake-up call

Breaking the rules: understanding non-compliance with policies and guidelines. | PSNet

psnet.ahrq.gov/issue/breaking-rules-understanding-non-compliance-policies-and-guidelines

September 24, 2018 - Breaking the rules: understanding non-compliance with policies and guidelines. … View more articles from the same authors. … 2018 Safety measurement and monitoring in healthcare: a framework to guide clinical teams … A systematic review of the literature. … NHS: learning lessons from other parts of the public sector?

Raising an alarm, doctors fight to yank hospital ICUs into the modern era. | PSNet

psnet.ahrq.gov/issue/raising-alarm-doctors-fight-yank-hospital-icus-modern-era

February 14, 2024 - Citation Text: Raising an alarm, doctors fight to yank hospital ICUs into the modern era. … View more articles from the same authors. … clinical teams caring for them. … The sinks can make the problem worse. … September 25, 2013 Patient monitoring alarms in the ICU and in the operating room.

Prescribing safely for children. | PSNet

psnet.ahrq.gov/issue/prescribing-safely-children

September 03, 2014 - View more articles from the same authors. … The authors describe challenges in prescribing medications for children, including common medication … December 18, 2014 A survey of nurses' beliefs about the medical emergency team system … September 30, 2012 The ritualisation of the surgical safety checklist and its decoupling … good, the bad, and the improvements.

Getting it right when things go wrong. | PSNet

psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong

October 20, 2014 - View more articles from the same authors. … May 21, 2019 Patient safety strategies: are we on the same team? … December 1, 2021 Just culture: the foundation of staff safety in the perioperative environment … 2017 Creating a fair and just culture: one institution's path toward organizational change … April 30, 2014 The meaning of justice in safety incident reporting.

Medicare takes aim at boomerang hospitalizations of nursing home patients. | PSNet

psnet.ahrq.gov/issue/medicare-takes-aim-boomerang-hospitalizations-nursing-home-patients

December 12, 2018 - View more articles from the same authors. … July 2, 2014 Half the time, nursing homes scrutinized on safety by Medicare are still … September 15, 2021 Organizational readiness to change as a leverage point for improving … May 15, 2019 Still Failing the Frail. … October 29, 2017 View More See More About The Topic Long-Term Care

Heparin: improving treatment and reducing risk of harm. | PSNet

psnet.ahrq.gov/issue/heparin-improving-treatment-and-reducing-risk-harm

July 28, 2021 - View more articles from the same authors. … November 11, 2020 Rapid response teams and continuous quality improvement. … August 4, 2021 Inaccurate penicillin allergy labeling, the electronic health record, … August 24, 2022 Root cause analysis of adverse events involving opioid overdoses in the … October 19, 2011 WebM&M Cases Watch the Warfarin!

Smart pumps in practice: survey results reveal widespread use, but optimization is challenging. | PSNet

psnet.ahrq.gov/issue/smart-pumps-practice-survey-results-reveal-widespread-use-optimization-challenging

December 27, 2018 - Smart pumps are considered an important tool to improve medication safety in the hospital environment … This newsletter article summarizes the results of two national surveys on smart infusion pump use to … Copy Citation Related Resources From the Same Author(s) IV push medications … June 16, 2019 Errors and discrepancies in the administration of intravenous infusions … November 1, 2017 The mixed blessings of smart infusion devices and health care IT.

Improving patient safety by shifting power from health professionals to patients. | PSNet

psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients

June 01, 2014 - View more articles from the same authors. … Kingdom motivated by the death of a pediatric patient to sepsis and the systemic weaknesses contributing … to the adverse outcome. … The articles discuss the importance effective communication between clinicians, caregivers, and patients … November 5, 2014 The potential for improved teamwork to reduce medical errors in the

CMS's hospital-acquired condition lists link hospital payment, patient safety. | PSNet

psnet.ahrq.gov/issue/cmss-hospital-acquired-condition-lists-link-hospital-payment-patient-safety

May 20, 2009 - View more articles from the same authors. … November 24, 2021 The science of safety improvement: learning while doing. … January 2, 2017 Improving patient safety—five years after the IOM report. … December 22, 2010 The intensive care unit, patient safety, and the Agency for Healthcare … March 13, 2013 NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the

Back to basics: counting soft surgical goods. | PSNet

psnet.ahrq.gov/issue/back-basics-counting-soft-surgical-goods

March 17, 2021 - View more articles from the same authors. … This commentary explores improvement efforts that focus on the role of teams in performing surgical … Same Author(s) We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 … March 17, 2021 Back to basics: the Universal Protocol. … January 16, 2013 The lost sponge: patient safety in the operating room.

Guideline for prevention of retained surgical items. | PSNet

psnet.ahrq.gov/issue/guideline-prevention-retained-surgical-items

April 26, 2023 - View more articles from the same authors. … April 26, 2023 Multifaceted interventions improve adherence to the surgical checklist … June 26, 2024 The association between nurse staffing and quality of care in emergency … September 22, 2021 Beyond the count: preventing the retention of foreign objects. … September 28, 2011 The frequency and significance of discrepancies in the surgical count

Hospitals slow to adopt patient apology policies. | PSNet

psnet.ahrq.gov/issue/hospitals-slow-adopt-patient-apology-policies

April 22, 2016 - View more articles from the same authors. … April 25, 2016 The human factor. … the time of COVID-19. … of a facility policy and organizational culture change. … the NHS: an online survey study.

Recognizing and managing errors of cognitive underspecification. | PSNet

psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification

November 14, 2018 - View more articles from the same authors. … Incomplete information transfer may create misunderstandings and prevent the establishment of a shared … : a scientific statement from the American Heart Association. … January 30, 2013 Handovers from the OR to the ICU. … January 23, 2013 The effects of a 'discharge time-out' on the quality of hospital discharge

Nursing peer review: developing a framework for patient safety. | PSNet

psnet.ahrq.gov/issue/nursing-peer-review-developing-framework-patient-safety

January 15, 2020 - View more articles from the same authors. … December 21, 2017 Understanding the heterogeneity of labor and delivery units: using … discrepancies between the shared medication record and patients' actual use of medication. … November 25, 2020 Targeting the fear of safety reporting on a unit level. … December 12, 2018 Bringing change-of-shift report to the bedside: a patient- and family-centered

Wrong-site surgery. | PSNet

psnet.ahrq.gov/issue/wrong-site-surgery-1

September 02, 2020 - View more articles from the same authors. … This commentary describes a case of wrong-site surgery , an erroneous breast biopsy, and the resulting … disclosure of the error and investigation. … The authors suggest that errors provide opportunities to design system solutions to prevent errors. … June 22, 2022 Rapid response teams as a patient safety practice for failure to rescue

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