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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - as the country proceeds in wide-scale implementation of EHR systems.(2)
The medical error, and subsequent … Although there are fewer studies of the accuracy of information in EHR systems, the results are more … Although there is a great deal of hope and optimism that more widespread use of EHR systems will
significantly … the adoption of electronic prescribing and EHR systems,
practitioners should keep in mind that these … The decade of health information technology: delivering consumer-centric and
information-rich health
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - The
patient was seen in the preoperative assessment clinic prior to admission, where the nursing staff … medication lists can originate at the level of the individual provider but also result from systems-based … Below are additional recommendations that can be employed at the health
systems level:
Hire and Train … the system.16 In case 2, the
nursing staff at the preoperative assessment clinic obtained an accurate … In case 2, dedicated
pharmacy staff at the preoperative assessment clinic would not only be able to
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - Learning Objectives Describe how health care providers should evaluate acute neurological deficits of … This situation facilitated the growth of the neurohospitalist specialty and the rise of telestroke systems … , information in the electronic health record, and “teleradiology” assessment of images. … due in part to safe and timely administration of intravenous thrombolysis with both systems. 16 However … Topic
Emergency Departments
Health Care Providers
Emergency Medicine
Neurology
Clinical
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - Companies Can Catch Up and Win and of many academic and consumer articles, which focus on optimizing … to explain what we were up to in terms of managing systems of care delivery, improving the processes … Frontline health care providers are challenged by poorly performing work systems. … Thus, it can be powerful to engage this army of creative minds and hands to improve work systems. … Hospitals
Health Care Providers
Health Care Executives and Administrators
Policy Makers
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Standardized Sedation Assessment
Nurses on the front line of patient care are tasked with administering … a patient after opioid administration include the timing
of the assessment, the pharmacokinetics and … Literature Review: Assessment of Opioid-related Sedation and the Pasero
Opioid Sedation Scale. … Evaluation of a Standardized Sedation Assessment for Opioid
Administration in the Post Anesthesia Care … University of Florida College of Medicine Pain Assessment
and Management Initiative.
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - health care providers, and protection against errors. … care provider or system, and others offered by outside vendors. … Robust personal health record systems are now available and will continue to flourish with the advent … September 27, 2016
Malpractice cases in breast surgery: an assessment of litigation involving … Topic
Emergency Departments
Ambulatory Clinic or Office
Health Care Providers
Information
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - and costs of the various systems and should be adopted with caution. … cognitive errors; unique patient population characteristics; and the systems or environment of care. … Assessment of emergency physician workforce needs in the United States, 2005. … computer systems and decision support? … A review of evidence, practice and consumer perspectives.
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - form of social media used to collect consumer feedback regarding quality improvement and service design … providers and not the public. … media sources that were used effectively to further engagement and communication amongst healthcare … providers to disseminate awareness of the World Health Organization’s Surgical Safety Checklist. 13 … Social Media as a Tool for Consumer Engagement in Hospital Quality Improvement and Service Design: Barriers
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - Second, I was excited and energized by the opportunity to use new tools available in the consumer space … RW : Have you seen examples of really robust integration of telehealth and other consumer-facing IT into … are seeing physician leadership and engagement propelling the modernization of clinical delivery systems … , in which patients are constantly connected to their health care providers. … Ambulatory Care
Health Care Providers
Information Professionals
Medicine
Surgical Complications
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - We have trained our surveyors in the most common electronic medical record systems. … We found too many instances where technology including EHRs, IV pumps, and monitoring systems don't talk … We're now teaching hospitals and systems how to use these tools as part of transformation, embed them … trajectory as automobile safety or as consumer electronics improvement. … MC : Hospitals and systems, a small but growing number, that have taken this challenge for high reliability
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psnet.ahrq.gov/periodic-issue/periodic-issue-282
March 15, 2021 - The Root Cause Analysis and Action (RCA2) framework supports the implementation of sustainable systems-based … Study
Assessment of patients' ability to review electronic health record information … care providers rely on cognitive decentering, collaborative decision-making, back-up behaviors, and contingency … The Root Cause Analysis and Action (RCA2) framework supports the implementation of sustainable systems-based … This narrative review identified knowledge gaps in the relationship between CPOE systems and how systems-related
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - Thus, a proper RCA includes an assessment of the environment (e.g., time of day, staffing levels, lighting … a regular assessment of medication doses, drug interactions, or key error prevention and patient safety … steps (e.g., daily assessment of the need for continued venous or urinary catheterization).( 12 ) Additionally … error, propose reasonable systems-based solutions, implement the changes, and then re-evaluate the process … Effects of computerized physician order entry and clinical decision support systems on medication safety
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Patients with T1D are
accustomed to knowing more about diabetes technology than many of their health … care providers and as a
result may be skeptical about inpatient recommendations for changes.7,12 Coupled … Shared decision making with the patient is imperative. 13 Assessment of patient
ability is also important … This will be increasingly important as more patients utilize CGMs and hybrid closed-loop systems
moving … An Overview of Safety Issues on Use of Insulin
Pumps and Continuous Glucose Monitoring Systems in the
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psnet.ahrq.gov/issue/another-look-medical-error
November 16, 2022 - August 30, 2023
Implementation and evaluation of a prototype consumer reporting system … intensive care units of 2 integrated health care systems. … July 15, 2002
Assessment of incorrect surgical procedures within and outside the operating … June 3, 2020
The intended and unintended consequences of communication systems on general … March 9, 2022
Guidelines for US hospitals and clinicians on assessment of electronic
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - health care providers who report that they have had education in this area. 7 Anchoring bias , or … ) when making decisions heavily influences health care providers as they go about their daily work. … structure of the handoff is adaptable to other health care providers and situations. 13
When clinicians … With the development of EHR, more clerical and administrative tasks fall on all healthcare providers, … Now more than ever, as the demands on healthcare workers reach new peaks and continue to change day-to-day
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - , Breathing, Circulation, Disability, and Exposure (ABCDE) assessment of the front and back of the patient … Adjuncts such as chest x-ray (CXR), pelvis x-ray, and/or the Focused Assessment with Sonography in Trauma … (MTP) in a trauma patient. 3 In most scoring systems, hypotension is prioritized, as is evidence of … Most scoring systems consider the activation of MTP, combined with other laboratory values and vital … Accuracy of Focused Assessment with Sonography for Trauma (FAST) in blunt abdominal trauma.
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - The Swiss cheese model , which demonstrates how systems with multiple checks in place can prevent errors … , referring clinicians and patients should be incorporated into a systems-level model for improving patient … Newer electronic methods can also be used to help ensure effective communication at the systems level … Improving communication by implementing multiple systems-based changes, using both e-methods and more … Hospitals
Ambulatory Clinic or Office
Health Care Providers
Physicians
Radiology
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psnet.ahrq.gov/periodic-issue/periodic-issue-335
April 27, 2022 - as the frequent use of verbal orders and the need for weight-based dosing. … training to healthcare workers, introducing risk management tools, and reducing preventable harm during … Advocates suggest that adjustments be made in curricula, instruction, and student assessment to address … Over the course of the following year, the patient’s son and daughter were contacted at various points … After a discussion of goals of care with the patient and daughter, he was enrolled in hospice.
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psnet.ahrq.gov/issue/validation-discharge-summary-term-search-method-detect-adverse-events
December 06, 2017 - March 10, 2021
Barriers and facilitators to improving patient safety learning systems … March 6, 2013
Assessment of the implementation of a national patient safety alert to … systems. … reported errors and vulnerability testing of current systems. … diagnostic errors in acute care across hospitals: early lessons from the Utility of Predictive Systems
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - The bed was low to the ground and locked in position, so she raised the bed up to perform her
assessment … After completing her assessment, the nurse left the room. … The safety of care provided in these systems depends not
only on the design and complexity of a particular … There is a great need for universal reporting and learning systems that leverage the power of
information … Systems approach and systems engineering applied to
health care: improving patient safety and health