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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - patient, performs comprehensive medical record review, and provides written recommendations. 33 In … By minimizing this information gap, a formal consultation would likely have prompted a more comprehensive … Pharmacotherapy Self-Assessment Program, seventh edition (PSAP-VII) Cardiology.2020:179-99. … Initial Results from a Cardiac Curbside Program. … October 30, 2024
Optimizing Pediatric Patient Safety in the Emergency Care Setting.
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - opioid use in opioid-naïve children. 1 Best practices for opioid prescribing include comprehensive … Approaches to Improving Safety System Optimization of EHR Opioid Prescribing Various safeguards may … The CDC recommends that prescribers check state prescription drug monitoring program (PDMP) data when … FDA Drug Safety Communication. … Patient Safety Day 2023.
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - and provides a more comprehensive understanding of why an adverse event occurred. … , but we must balance our safety programs to ensure human factors training exists for front-line clinical … July 13, 2016
Profiles in patient safety: medication errors in the emergency department … April 6, 2011
View More
Related Resources
Patient Safety … Innovations
Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - opioid use in opioid-
naïve children.1 Best practices for opioid prescribing include comprehensive … Approaches to Improving Safety
System Optimization of EHR Opioid Prescribing
Various safeguards may … The CDC recommends that prescribers check state prescription drug monitoring
program (PDMP) data when … Take-Home Points
Education on opioid safety including adverse effects, appropriate dosing, and storage … FDA Drug Safety Communication.
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - programs. … Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports … to the UK National Patient Safety Agency. … December 3, 2008
Effect of a central call center on employee perceptions of safety culture … June 5, 2019
Implementation of the I-PASS handoff program in diverse clinical environments
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - frequency with which such events occur, and track the progress of safety initiatives over time. … Survey respondents also endorsed the importance of formal support programs, including peer support, education … ICPs at a comprehensive cancer center. … to improving safety. … This study analyzed 145 safety incidents related to telehealth at the VHA.
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news … This study analyzed 145 safety incidents related to telehealth at the VHA. … ICPs at a comprehensive cancer center. … Survey respondents also endorsed the importance of formal support programs, including peer support, education … This study analyzed 145 safety incidents related to telehealth at the VHA.
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psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
March 01, 2012 - Take disclosure-and-offer programs, for example. … After all, in most of these programs, the institution makes its own determination of compensability. … Finding the solution is going to require firm evidence and more research on comprehensive reforms. … We have seen the launch of a small number of projects testing newer and more comprehensive interventions … Liability claims and costs before and after implementation of a medical error disclosure program.
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Maternal safety refers to the safety of a person during pregnancy, childbirth, and the postnatal … and Social Determinants of Maternal Safety 6
Given the importance of safety as a positive concept … , PhD
Associate Professor, School of Information and Library Science
Carolina Health Informatics Program … opportunity to approach this with our strong programs of work and our good ideas. … So, folks who were getting weekly appointments who are on Suboxone in a substance use disorder program
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - and families in healthcare decisions about patient care and in hospital and health system policy and programs … .” 2
To define the roles of patients and families in safety , the Canadian Patient Safety Institute … Centered Care’s (IPFCC) Better Together: Partnering with Families campaign and developed a more comprehensive … This organization has some helpful materials for a program called Essential Together . … Children’s National Hospital has a “Navigator Program” for families caring for children with complex
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - opportunity to approach this with our strong programs of work and our good ideas. … So, folks who were getting weekly appointments who are on Suboxone in a substance use disorder program … safety refers to the safety of a person during pregnancy, childbirth, and the postnatal period. … and Social Determinants of Maternal Safety 6
Given the importance of safety as a positive concept … , PhD
Associate Professor, School of Information and Library Science
Carolina Health Informatics Program
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - These best practices include, but are not limited to, comprehensive
identification and assessment of … proper use of PCA prior to initiation
Table adapted from ISMP 20038 and the San Diego Patient Safety … Safety Issues with Patient Controlled Analgesia Part II - How To Prevent Errors
ISMP Medication Safety … San Diego Patient Safety Council. … Safety).
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - patient safety field. … There are
also programs that teach health knowledge – such as how a specific disease affects the body … Strictly
speaking, these efforts only fit the definition of a health literacy improvement program if … in health literacy self-assessment and make health
literacy part of the fabric of their safety and … quality programs.
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - program involving feedback improves the accuracy of image interpretation.( 11 ) Radiologists participating … in these programs regularly review a standard set of films, with feedback on the findings they missed … Advances in patient safety: from research to implementation. … So when you enter a set of symptoms or signs, our search engine works off a very comprehensive database … Considerations in Building a Point-of-Care Ultrasound Program
June 1, 2018
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - care. 31 , 34 Approaches to Improving Safety and Patient Outcomes By adhering to the following practices … Postoperative Measures After carpal tunnel release surgery, provide clear and comprehensive postoperative … Quality Improvement Approach Optimizing the healthcare system to assure safety and minimize infections … Quality Control and Improvement : Implement a quality improvement program to monitor outcomes and identify … An American View of the UK's Patient Safety Enterprise: Top Down vs.
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - to the real important point and that is patient safety. … Take disclosure-and-offer programs, for example. … Finding the solution is going to require firm evidence and more research on comprehensive reforms. … We have seen the launch of a small number of projects testing newer and more comprehensive interventions … Liability claims and costs before and after implementation of a medical error disclosure program.
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - part due to all of these challenges, current CDS systems have not achieved broad acceptance and such comprehensive … Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health … Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals … Do safety checklists improve teamwork and communication in the operating room? A systematic review. … April 25, 2016
Using Lean to improve medication administration safety: in search of the
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - Civilian Peer Review of Military Care program, and the Executive Vice President of the Massachusetts … listed by the department to engage in Patient Safety Activities, reviewing the quality and safety of … WM : The entire PSO program is voluntary for everyone except AHRQ, which obviously administers the program … We have tried to address that problem in the PSO program through the common definitions and reporting … time, as we all were developing a greater understanding of what it would take to successfully provide comprehensive
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - approaches that can enhance the quality and safety of our health care system. … A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. … May 16, 2012
Improving departmental psychological safety through a medical school-wide … Health system redesign of cardiac monitoring oversight to optimize alarm management, safety … Topic
Hospitals
Health Care Providers
Quality and Safety Professionals
Anesthesiology
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - The patient safety goal is to systematically curate surgical item management practices and improve the … Comprehensive, multi-modal, team-based approaches that address both technology and clinician practices … , and ambulatory care surgical sites often develop site-specific or systemwide actions and training programs … The Swiss cheese model of safety incidents: are there holes in the metaphor?. … February 9, 2022
The nature of reported safety events related to care coordination in