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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - and controversy about the purpose and usefulness of these systems. … However, since 2000, the number of states with authorized systems has almost doubled, and many of the … As state experience with reporting systems grows, the systems continue to evolve and mature. … the more recent systems requires the availability of facility-specific data. … , or other licensed health care provider
Abduction of a patient of any age
Sexual assault on a patient
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psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit
May 25, 2016 - Traditionally, health systems have disclosed adverse events to patients only through a lengthy process … and emphasizing protection of the clinicians involved. … The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative … A PSNet interview with the chief risk officer of the University of Michigan Health System discusses … the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events.
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psnet.ahrq.gov/issue/ahrq-patient-safety-youtube-channel
December 24, 2008 - Each set of videos provides examples of learning tactics to address the needs of individual learners … Summary, Evidence Report/Technology Assessment. … Consumer Reporting System for Patient Safety Events. … March 22, 2016
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Hospitals
Health … Care Providers
Health Care Executives and Administrators
Educators
Medicine
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psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-0
May 26, 2010 - May 2, 2018
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer … Evidence Report/Technology Assessment. … December 9, 2009
Industrial and Systems Engineering and Health Care: Critical Areas of … During and Immediately After Childbirth: State of the Science. … October 26, 2022
Evaluation of the culture of safety and quality in pediatric primary
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psnet.ahrq.gov/issue/psychology-error-relation-medical-practice
January 11, 2006 - February 10, 2016
Simulation-based assessment of the management of critical events by … A review of evidence, practice and consumer perspectives. … July 17, 2019
Clinical reasoning assessment methods: a scoping review and practical guidance … systems level. … : literature review and the development of the surgical stress effects (SSE) framework.
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psnet.ahrq.gov/issue/digitizing-diagnosis-review-mobile-applications-diagnostic-process
October 10, 2018 - Although the authors described some of the potential benefits of these apps, they note that their research … October 10, 2018
The Psychological Safety Scale of the Safety, Communication, Operational … overlooked by health care providers. … August 26, 2015
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Hospitals
Health … Care Providers
Health Care Executives and Administrators
Information Professionals
Diagnostic
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psnet.ahrq.gov/issue/evidence-nurses-need-participate-diagnosis-lessons-malpractice-claims
September 12, 2018 - as a contributing factor were associated with a higher risk of death (odds ratio [OR]=3.01 and 2.21, … them in the diagnostic process, such as competency training and assessment. … September 28, 2017
Call me Ishmael: addressing the white whale of team communication … March 1, 2023
To err is human, unless you are a healthcare provider. … June 22, 2009
We're not your enemy: an appeal from a consumer to re-imagine tort reform
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psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-reports
December 24, 2008 - In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National … The 2023 report discusses the continued impact of COVID-19 on United States health care delivery. … It also reviews the current status of special areas of interest such as telehealth and nursing home … Summary, Evidence Report/Technology Assessment. … Long-Term Care
Ambulatory Care
Health Care Providers
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psnet.ahrq.gov/issue/research-activities
December 24, 2008 - Summary, Evidence Report/Technology Assessment. … December 22, 2014
Developing and Testing the Health Care Safety Hotline: A Prototype … Consumer Reporting System for Patient Safety Events. … of Diagnosis. … March 5, 2008
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Health Care Providers
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - President Clinton's 1996 Advisory Commission on Consumer Protection and Quality in the Health Care Industry … These core measures would provide a foundation for reporting systems that facilitate the capture of quality … The long road to patient safety: a status report on patient safety systems. … of the President's Advisory Commission on Consumer Protection and Quality. … systems have to fundamentally reform themselves to meet the mandate.
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - I further propose that the
liberated neurons be used to store the tools and concepts of human factors … care providers, I have found that the concepts of human factors engineering often
inspire two types … He removes the catheter while the patient is seated, instead of in the much safer
supine position, and … Moreover, they appreciate that the average
consumer has seen two-nostril administration demonstrated … Cognitive and usability engineering methods for the evaluation of clinical
information systems.
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - of the President's Advisory Commission on Consumer Protection and Quality. … systems have to fundamentally reform themselves to meet the mandate. … President Clinton's 1996 Advisory Commission on Consumer Protection and Quality in the Health Care Industry … These core measures would provide a foundation for reporting systems that facilitate the capture of quality … The long road to patient safety: a status report on patient safety systems.
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psnet.ahrq.gov/issue/towards-framework-managing-risk-associated-technology-induced-error
May 10, 2013 - The authors outline potential risks present at the time of purchasing the technology and during pre … United States of America and England. … through the development and adoption of a computer-assisted tool with automated electronic integration … November 3, 2015
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Hospitals
Health … Care Providers
Information Professionals
Medicine
Epidemiology of Errors and Adverse Events
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psnet.ahrq.gov/issue/reducing-errors-health-care-translating-research-practice
October 23, 2019 - Rockville, MD: Agency of Healthcare Research and Quality; AHRQ Publication No. 00-PO58. … Patients at risk, types of medical errors, and ways to improve and promote patient safety are discussed … Summary, Evidence Report/Technology Assessment. … Consumer Reporting System for Patient Safety Events. … March 5, 2008
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Health Care Providers
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psnet.ahrq.gov/issue/understanding-human-over-reliance-technology
February 24, 2016 - Reviewing how the tendency to trust in the correctness of information from technology can diminish human … clinicians to assess the reliability of the technology with monitoring and verification activities … Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared … October 7, 2008
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Hospitals
Health … Care Providers
Information Professionals
Patients
Medicine
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - In the ED, the patient complained of pain in her epigastric region and back. … Technology-based systems interventions, such as the use of text or pager alerts to communicate critical … Take-Home Points Health care providers, especially acute care providers in the emergency and inpatient … Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking … A review of evidence, practice and consumer perspectives.
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psnet.ahrq.gov/issue/advising-patients-about-patient-safety-current-initiatives-risk-shifting-responsibility
May 20, 2015 - Several of the major safety-related organizations (including Agency for Healthcare Research and Quality … The authors of this study reviewed the five primary patient safety brochures and interviewed their developers … actions, and that some of the shifting of responsibility for safety from providers and/or institutions … October 12, 2018
Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities … Topic
Health Care Providers
Quality and Safety Professionals
Patients
Provider-Patient
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - With systems based on triggers, there are problems
with the inherent performance of those triggers and … It's our duty as health care
providers to try to provide that care. … At
the end of it, we come out with scores that represent the panel's assessment of the usability of … PR: Acting as an individual consumer, I probably wouldn't give the PSIs a lot of weight in my own choice … and more hospitals will be implementing sophisticated EHR systems.
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psnet.ahrq.gov/issue/risk-management-radiology-departments
January 03, 2007 - of quality systems, enhanced competency, transparency, and evidence-based protocols as ways to augment … November 16, 2022
Assessment of the use of patient vital sign data for preventing misidentification … overlooked by health care providers. … November 8, 2006
Assessment of the potential impact of a reminder system on the reduction … Care Providers
Risk Managers
Radiology
Epidemiology of Errors and Adverse Events
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psnet.ahrq.gov/issue/national-coordinating-council-medication-error-reporting-and-prevention
April 15, 2015 - nationwide campaign for medication error reporting and prevention which includes a index on types of … Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. … April 6, 2022
The effects of leadership for self-worth, inclusion, trust, and psychological … January 29, 2018
Adverse drug event reporting systems: a systematic review. … December 10, 2008
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Health Care Providers