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psnet.ahrq.gov/issue/safety-information-alaris-se-infusion-pumps
June 07, 2006 - : Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. … care providers. … SARS-CoV-2--letter to clinical laboratory staff and health care providers. … April 30, 2014
Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples … September 7, 2022
Letter to Health Care Providers: Safe Use of Surgical Staplers and
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - in the control of the healthcare professional, patient, or consumer.” … is at the center of cross-cultural care. 24 Healthcare providers can build trusting relationships and … the patient and caregiver(s) with the educational information, the healthcare provider should use non-shaming … If the patient and caregiver are not able to teach-back correctly, the healthcare provider should rephrase … Caregivers play an integral role in supporting the plan of care, and healthcare providers should engage
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - He is also coeditor of the ISMP consumer website, chairperson of the International Medication Safety … We also have a consumer website and a Consumer Medication Errors Reporting Program , so we hear from … the name of the drug and know what to expect when they got to the pharmacy. … an ST-PRA [sociotechnical probabilistic risk assessment] project where we met with groups of pharmacists … Automated renewal systems are a major issue.
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psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - 1), her case highlights
the challenges and perils of "cross-coverage," the management of patients by … Without a complete history, a physical exam, and a full assessment of a patient's problems,
providing … Checklists (7) and signout cards (8) may decrease the risk of
error and improve the satisfaction of … signout database systems are two examples of relatively simple, inexpensive interventions that can … improve signouts and cross-coverage while more expensive and complex systems are being
implemented.
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - a wad of
packing material was in the vagina, health care providers in this Case relied on perfunctory … Such systems usually include (1) use of packing materials with radiopaque markers, which must not
be … Organizational
culture should encourage health care providers to communicate and collaborate with each … Systems analysis of adverse drug events. J Am Med Assoc.
1995;274(1):35-43.
9. Farrell G. … Applying the knowledge of nursing procedures and psychomotor skills to the
techniques of physical assessment
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Approach to Improving Safety and Systems Change Needed
To help clinicians avoid similar errors, hospitals … Forcing Functions
Forcing functions are automatic, built in features of systems designed to minimize … Systems-level changes like checklists and forcing functions, when integrated into the EHR, provide
additional … Checklists and forcing functions are two tools that healthcare providers can use to mitigate cognitive … Assessment of a Best Practice Alert and Referral Process
for Preprocedure Antithrombotic Medication
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - systems. … health care providers, and protection against
errors. … care provider or system, and others offered by
outside vendors. … Developing effective information technology systems will require the involvement of not only patient … Robust personal health record systems are now available and will continue to flourish with the
advent
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - For the better care part of it, we used HCAHPS [Hospital Consumer Assessment of Healthcare Providers … and Systems] scores to measure patient experience. … Finally, growing pressures to improve quality and safety created a new paradigm which emphasized systems … Far from being a threat to the hospitalist model, I can easily see health systems embracing a hybrid … need for systems improvement.
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - treatment of acute pain and pain associated with advanced cancer or
suffering at the end of life. … Risk mitigation measures, such as urine toxicology screening, patient contracts, and risk assessment … prescriber PDMP use and providing
integrated query systems that minimize provider burden will help … While there are no perfect risk
assessment instruments, universal screening and triaging of chronic … Given the
magnitude, duration, and persistence of the opioid epidemic, no one of these interventions
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psnet.ahrq.gov/node/33703/psn-pdf
November 01, 2010 - The transfer of patients
between systems, lack of staff training or experience in documenting patients … associated with the
event.(6) However, the usefulness of incident reporting systems for measurement … and comparison of
data across systems untenable. … Data elements across health care systems are not consistent, and the accuracy and
reliability of ICD … inaccuracy of ICD-9-CM
codes across and within systems, may
detect high proportion of false positives
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - Understand the hazards of alert fatigue in automated results management systems. … The National Committee for Quality Assurance
(NCQA) includes implementation of reliable systems to effectively … Well-designed systems also classify the degree of the abnormality for each
result (e.g., mild, moderate … and capabilities of an ideal laboratory results
management systems are shown in the Table.(16,17) … "(19) Another physician stated, "One of the issues is just the sheer volume of alerts, and there are
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psnet.ahrq.gov/periodic-issue/periodic-issue-428
February 28, 2024 - Study
A qualitative study of systems-level factors that affect rural obstetric … : early lessons from the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study. … This article describes how the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) Study identified … to by their health care provider or treated with disrespect … The commentary highlights strategies to improve EHR systems to prevent diagnostic delays and care coordination
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psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Nevertheless, hospitals need to respond, adapt, and
evolve their care delivery systems, particularly … case presented, but these prevention steps along with the HCW's
knowledge of his history and past exposures … Early on, the cause and extent of
disease, including the transmission potential, are often unknown. … In the case of a suspected biothreat, the CDC partners with EDs and other frontline sites to conduct … necessarily represent the
views of AHRQ.
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. … Automated measures of hand hygiene compliance among healthcare workers using ultrasound: validation and … There are systems that are RFID-linked, recognizing the time and exact amount of product used at the … Other systems monitor the gestures of the health care workers, or the amount of time and where and when … "Influenza-like" symptoms and work-related behavior among healthcare workers and other professionals:
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - Study
Characteristics and trends of medical diagnostic errors in the United States … and ethical consequences of medical errors and error reporting using the RaDonda Vaught case as an exemplar … A qualitative study among patients, carers and healthcare providers. … When patients, carers, and healthcare providers describe potential patient safety consequences of technology … The data can be applied to inform the development of population-level improvement strategies and track
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - Association of Medical Directors of Information Systems consensus on inpatient electronic health record … Even though I and others have written about some of the downsides of the electronic medical record, we … Here's what I see a lot: 14-point review of systems with negatives as follows, and 80 items are listed … If I see a student or a resident blatantly copying the intellectual assessment of someone else, I call … Part of the reason I'm pulling forward that neuro exam day after day or that review of systems is because
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psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
August 22, 2014 - The first one for me is consumer technology. … reminder and tracking systems that push alerts and reminders to the clinicians (and eventually to the … Systems need to be able to track tests and procedures over the course of months or even years, helping … Development of a personalized bidirectional text messaging tool for HIV adherence assessment and intervention … Topic
Ambulatory Care
Health Care Providers
Health Care Executives and Administrators
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - Radiologists are responsible for the production and delivery of the radiology report, and
referring … 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
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psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
May 14, 2020 - He also serves as the Chief of the Innovative Practice and Telehealth Section of the Department of Emergency … However, interestingly enough, the accelerant for our telehealth systems actually came from our outpatient … ahead of time and make sure the patient can connect. … That being said, I think it is still incumbent on us as healthcare providers to prioritize patients’ … event as a result of delayed assessment and treatment.
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - Case Objectives Describe the appropriate initial assessment of patients with chronic non-cancer pain … on prescription medications and specifically reported the doses of opioids prescribed and the nature … disorders, and who was marginally housed and lacked support systems. … Take-Home Points The initial assessment in managing patients with chronic non-cancer pain should … Topic
Hospitals
Health Care Providers
Risk Managers
Public Health
Opiates/Narcotics