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psnet.ahrq.gov/issue/analysis-suicides-reported-adverse-events-psychiatry-resulted-nine-quality-improvement
October 21, 2020 - Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment … and documentation in the heath record to be insufficient. … The authors outline quality improvement recommendations focused on improving documentation, suicide assessment … and intervention training, and improving communications with families, caregivers, and other health … care providers.
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - and hospitals that do not buy the equipment) further weaken the market position of health care providers … When government incentives and punishments (reduced reimbursements) compel health care providers to purchase … Costs and Benefits of Health Information Technology. Evidence Report/Technology Assessment No. 132. … case for health care providers and organizations to have information technology (IT) systems in 2012 … of the provider community and, hopefully, ultimately the consumer community as well.
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psnet.ahrq.gov/issue/sorry-never-enough-how-state-apology-laws-fail-reduce-medical-malpractice-liability-risk
May 05, 2021 - As a result, 38 states and the District of Columbia passed apology laws , designed to make such apologetic … Same Author(s)
To err is system: a comparison of methodologies for the investigation of … need to address unconscious bias within health systems. … March 27, 2019
Effects of a communication-and-resolution program on hospitals' malpractice … December 19, 2018
Transparent and open discussion of errors does not increase malpractice
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psnet.ahrq.gov/issue/link-between-clinically-validated-patient-safety-indicators-and-clinical-outcomes
November 16, 2016 - August 30, 2023
The impact of meaningful use and electronic health records on … composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans … February 17, 2017
Consumer rankings and health care: toward validation and transparency … May 28, 2015
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See More About The Topic
Hospitals
Health Care … Providers
Medicine
Epidemiology of Errors and Adverse Events
Patient Safety Indicators
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - ISMP advises
patients to insist that their physicians inform them of the generic and brand names of … dose and
complexity of medication regimens in the elderly. … Patients must insist that their physicians inform
them of the generic and brand names of each of their … medications, as well as the spelling of and
indications for each. … A randomized, controlled trial of comprehensive geriatric
assessment and multidisciplinary intervention
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psnet.ahrq.gov/node/33763/psn-pdf
March 01, 2014 - of 14 experts that provides advice and guideline
development for the Department of Health and Human … , the vision and infrastructure for national surveillance and reporting systems for HAIs was born. … The systematic collection
of these data and provision of reports allows for local, state, and national … and national validation systems to ensure fair and objective reporting was identified; such systems are … Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care
Hospital
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psnet.ahrq.gov/perspective/emergence-application-based-healthcare
August 05, 2022 - Sustainable reimbursement and payment mechanisms to healthcare facilities and healthcare providers for … Google: the evidence on consumer-facing digital tools for diagnosis. … Google: the evidence on consumer-facing digital tools for diagnosis. … providers, I’m wondering what your overall perspective is on the current state of app-based healthcare … General Public
Health Care Providers
Quality and Safety Professionals
Patients
Family
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - However, the role of physicians in creating better systems and how they work with others in effective … The question is, as we get smarter about the processes and systems in organizations, will we be able … understanding of systems thinking and engineering principles—was a marvelous example of translocational … Evidence Report/Technology Assessment No. 43. … March 16, 2022
Two decades since To Err Is Human: an assessment of progress and emerging
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psnet.ahrq.gov/issue/patient-education-prevent-falls-among-older-hospital-inpatients-randomized-controlled-trial
February 14, 2017 - February 14, 2017
Insights into the climate of safety towards the prevention of falls … ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative … to patient deterioration—developing a model for consumer reporting. … July 24, 2019
Use of standard risk screening and assessment forms to prevent harm to … Topic
General Hospitals
Health Care Providers
Risk Managers
Quality and Safety Professionals
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - of pain as a "fifth vital sign," and the inclusion of pain-related questions on the HCAHPS [Hospital … Consumer Assessment of Healthcare Providers and Systems] survey, whose results can affect hospital … system as a whole encouraged increasing use of opioids and overlooked the risk of misuse. … In this sense,
the opioid epidemic is iatrogenic, and thus falls within the scope of patient safety. … The guidelines also suggest minimizing concurrent use of opioids and other sedating
medications and
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psnet.ahrq.gov/issue/are-more-experienced-clinicians-better-able-tolerate-uncertainty-and-manage-risks-vignette
March 08, 2023 - Risk aversion in clinical practice may lead to the ordering of unnecessary tests and procedures, a … healthcare staff in the United Kingdom and Australia. … March 31, 2021
The role of emotion in patient safety: are we brave enough to scratch … August 10, 2022
Emotion and coping in the aftermath of medical error: a cross-country … A review of evidence, practice and consumer perspectives.
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psnet.ahrq.gov/issue/research-designs-studies-evaluating-effectiveness-change-and-improvement-strategies
September 20, 2011 - Research designs for studies evaluating the effectiveness of change and improvement strategies. … They discuss the nuances of selecting randomized versus non-randomized approaches and the tradeoffs of … of medication safety letters issued in Canada, the USA and the UK. … May 18, 2022
An analysis of the structure and content of dashboards used to monitor patient … systems.
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psnet.ahrq.gov/issue/inadequate-health-literacy-among-paid-caregivers-seniors
May 04, 2010 - Same Author(s)
Results of the Medications At Transitions and Clinical Handoffs (MATCH) … February 18, 2011
Choice, transparency, coordination, and quality among direct-to-consumer … of the literature. … March 23, 2011
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Related Resources
Assessment of patient-preferred … See More About The Topic
Ambulatory Care
Health Care Providers
Quality and Safety Professionals
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - Research and Quality (AHRQ) released an assessment of the role of health information technology in enabling … Patient engagement embodies consumer empowerment, health advocacy, and patient activism—activities that … the medical record.( 6 ) Using a similar approach, patient safety reporting systems designed specifically … consumer organizations are increasingly interested in soliciting and sharing consumer-reported patient … Designing Consumer Reporting Systems for Patient Safety Events.
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psnet.ahrq.gov/issue/evaluation-intervention-aimed-improving-voluntary-incident-reporting-hospitals
December 16, 2020 - incidents, changes in the process to reduce the fear of reporting, a shorter reporting form, and newsletters … September 26, 2018
Consumer perceptions of safety in hospitals. … June 18, 2019
Comparing the outcomes of reporting and trigger tool methods to capture … A social network analysis and examination of prescribing error rates. … October 26, 2010
Development of the ICU safety reporting system.
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2023 - The relationship between nurse staffing and the quality and safety of care has been reported. … This commentary highlights the importance of educational initiatives, mentors, and use of clinical
decision … Value assessment of deprescribing interventions: suggestions for improvement. … This commentary highlights the importance of educational initiatives, mentors, and use of clinical
decision … The relationship between nurse staffing and the quality and safety of care has been reported.
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psnet.ahrq.gov/issue/personal-nursing-care-experiences-provide-lessons-patient-safety
March 01, 2023 - practices: a qualitative assessment. … June 4, 2014
Observer-based tools for non-technical skills assessment in simulated and … January 12, 2011
Understanding how rapid response systems may improve safety for the … from using computerized provider order entry systems in primary and secondary care. … March 18, 2020
Health care provider factors associated with patient-reported adverse
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psnet.ahrq.gov/issue/emerging-ehr-purgatory-moving-process-outcomes
July 22, 2020 - to enhance the ability of electronic health record systems to deliver on promises of improved safety … June 14, 2017
Assessment of automating safety surveillance from electronic health records … , and healthcare worker well-being. … August 20, 2008
Using the Communication and Teamwork Skills (CATS) assessment to measure … March 15, 2023
Assessment of the use of patient vital sign data for preventing misidentification
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psnet.ahrq.gov/periodic-issue/periodic-issue-429
February 28, 2024 - Respondents discussed the importance of communication, effective leadership, and building systems that … The clinicians were generally positive about consumer involvement, but were also concerned that it could … This review explored studies on electronic medication reconciliation tools available to healthcare providers … programs can target the various stages of recovery to support healthcare workers after a patient safety … The commentary highlights strategies to improve EHR systems to prevent diagnostic delays and care coordination
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psnet.ahrq.gov/issue/strategies-prevent-missed-nursing-care-international-qualitative-study-based-upon-positive
May 18, 2022 - Same Author(s)
Observational evidence of the prevalence and association of polypharmacy … November 11, 2020
The work of nurses to provide good and safe services to children receiving … hospital-at-home: a qualitative interview study from the perspectives of hospital nurses and physicians … October 20, 2021
Can patients contribute to enhancing the safety and effectiveness of … April 21, 2021
Incorporating nursing complexity in reimbursement coding systems: the