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Dying in the Hospital With Advanced Dementia | PSNet

psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia

November 01, 2016 - Case Objectives Recognize the importance of eliciting patient preferences and goals of care at the … What is appropriate health care for end-stage dementia? J Am Geriatr Soc. 1993;41:25-30. … Churning: the association between health care transitions and feeding tube insertion for nursing home … bias with use of health care algorithms. … Topic Hospitals Health Care Providers Facility and Group Administrators Neurology

Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet

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January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk … Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. … Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. … , is used in a variety of settings both in and out of the hospital. 12 The benefits of human milk feeding … health care.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes) | PSNet

psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical

February 26, 2025 - Buy-in from families and the patient’s team of healthcare providers Unit physician and nursing champions … Buy-in from families and the patient’s team of healthcare providers Unit physician and nursing champions … Utilizing co-production to improve patient-centeredness and engagement in healthcare delivery: lessons … Institute of Medicine Committee on Quality of Health Care in America. … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter

In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety | PSNet

psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety

December 14, 2022 - We, along with the guidance of multiple stakeholders (e.g., patients, clinicians, health care facilities … framework for quality: safe, timely, effective, equitable, efficient, and patient-centered care. … We also have a goal to advance resiliency in the health care system, which has been a big lesson of the … Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson … Health Care Safety During the Pandemic and Beyond—Building a System That Ensures Resilience.

The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns | PSNet

psnet.ahrq.gov/issue/co-design-implementation-and-evaluation-serious-board-game-playdecide-patient-safety-educate

September 12, 2018 - 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting … junior doctors about patient safety and the importance of reporting safety concerns. … “Serious games” are becoming more prevalent in health care. … junior doctors about patient safety and the importance of reporting safety concerns. … responsibility for healthcare: a typology for understanding differing attributions in the context of

In Conversation With… Alison Holmes, MD, MPH | PSNet

psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph

March 01, 2014 - If you were in charge of the health care system in the United States would you build in such targets … RW : It strikes me that embedded in that rationale is a larger tension in health care—the role of the … But in terms of prioritization it will depend on what health care systems can offer. … efforts to ensure the safety of patients in the health care system. … Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection

In Conversation with Edwin Boudreaux about Suicide Prevention | PSNet

psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention

March 25, 2025 - Often in health care, we get deep into the details of what that protocol looks like. … Sarah Mossburg : I love that reminder to return to relationship-based patient-centered care as the fundamental … Health care contacts in the year before suicide death. J Gen Intern Med . 2014;29(6):870-877. … the majority of people who die by suicide have interacted with the healthcare system in the weeks or … Variation in patterns of health care before suicide: a population case-control study.

Patient Engagement and Patient Safety | PSNet

psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety

February 01, 2013 - A Google search of this phrase identified 335,000 hits, while a search of the related term "patient-centered … patient-centered care ( 2 ), and the Patient-Centered Outcomes Research Institute (PCORI) announced … As we embrace the role of patients and their caregivers at multiple levels of the health care system, … Enabling Patient-Centered Care Through Health Information Technology. … Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care.

Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet

psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple

January 29, 2021 - to deliver more patient-centered care, enable shared decision-making, and ensure that informed consent … This case clearly demonstrates that a medical interpreter is an indispensable part of the health care … patient or by any member of the health care team. … Overcoming communication barriers in refugee health care. … What is needed in culturally competent healthcare systems?

Airway Obstruction during Anterior Cervical Spine Surgery | PSNet

psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery

January 29, 2021 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … To prevent exacerbating the neurologic deficit, it is of utmost importance for the anesthesia clinician … Simulation has been shown to improve knowledge, skill, and behavior of health care professionals. 18,19 … Distractions in the operating room: a survey of the healthcare team. … Qual Saf Health Care . 2005;14(3):156-163. [ Free full text ] Shailaja S, Hilda SS, Pinto PA, et al.

Beyond the Hospital: the New Frontier of Patient Safety | PSNet

psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety

August 01, 2014 - patients safe, where the world of health care meets the real world of patients' everyday lives. … Qual Saf Health Care. 2004;13(suppl 1):i85-i90. [go to PubMed] 18. … and the development of patient-centered medical homes and team-based care, I actually feel somewhat … RW : At one level, you're describing a data overload for the clinician or the medical home that's trying … RW : People talked about the lack of teams in health care as being partly we've never had the organizational

EMS Patient Safety in the Field | PSNet

psnet.ahrq.gov/perspective/ems-patient-safety-field

July 28, 2021 - They are in the unique position of providing medical care, often critical or emergent, outside of a healthcare … is of paramount importance and of great concern due not just to a desire to protect workers, but also … importance of safety incident reporting. 11 , 12 , 13 , 14 Simulations are an effective technique that … healthcare that operates primarily outside of a healthcare facility. … This is in contrast to other healthcare settings along the care continuum that align with the U.S.

The Hidden Danger of Unseen Intravenous Catheters | PSNet

psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters

October 04, 2023 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Agency for Healthcare Research and Quality (AHRQ), U.S. … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … June 14, 2017 Vital signs: epidemiology of sepsis: prevalence of health care factors

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet

psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions

November 16, 2022 - Qual Saf Health Care . 2006;15(Suppl I):i50–8. 5. … Older adult patients and care partners as knowledge brokers in fragmented health care. … on the healthcare delivery side. … The entire process has now been implemented for every patient in all of the EDs of that healthcare system … Topic Researchers Emergency Departments Long-Term Care Health Care Providers Health

Patient Safety in Office-Based Care Settings | PSNet

psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings

January 31, 2024 - Medicine (US) Committee on Quality of Health Care in America. … Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients. … patient in the healthcare delivery system. … barriers and roadblocks in the healthcare system as well as the treatment plan. … Ambulatory Clinic or Office Health Care Providers Health Care Executives and Administrators

Operationalizing Patient Safety at Academic Medical Centers | PSNet

psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers

August 01, 2010 - , innovative, state-of-the-art health care. … Hierarchies: the Berlin wall of patient safety. Qual Saf Health Care. 2006;15:229-230. … The human factor: the critical importance of effective teamwork and communication in providing safe care … Healthcare Systems Ergonomics and Patient Safety. London, UK: Taylor & Francis Group; 2005:85. … RS: I cannot underscore enough the importance of leadership at some senior level in the organization

Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet

psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training

February 28, 2024 - A growing body of evidence shows the importance of TeamSTEPPS in improving communication and teamwork … Recently, the COVID-19 pandemic highlighted the importance of team training in dealing with unexpected … Developing cognitive skills through active learning: a systematic review of health care professions. … A number of healthcare systems decided to implement TeamSTEPPS, and those organizations were important … With a need to engage every member of the health care team, including patients and caregivers, it became

Resilient Healthcare and the Safety-I and Safety-II Frameworks | PSNet

psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks

December 14, 2022 - Resilient healthcare reflects the capacity of the entire healthcare system to adjust to challenges and … Resilient health care: turning patient safety on its head. … Ellen Deutsch: About 10 years ago, I was privileged to attend one of the early Resilient Health Care … of the complexity of healthcare systems. … Topic Researchers Hospitals Ambulatory Care Health Care Providers Health Care Executives

Cybersecurity and How to Maintain Patient Safety | PSNet

psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety

March 27, 2024 - of Cyberattacks Cyber attackers gain access to healthcare systems through tactics like phishing , … Among the most common and disruptive types of cyberattacks in healthcare is ransomware, which encrypts … https://aspr.hhs.gov/cyber/Documents/Health-Care-Sector-Cybersecurity-Dec2023-508.pdf 3. … In many healthcare organizations, the event reporting system is part of the DNA of how operations report … Topic Hospitals Health Care Providers Health Care Executives and Administrators Information

Duke Center for Healthcare Safety and Quality. | PSNet

psnet.ahrq.gov/issue/duke-center-healthcare-safety-and-quality

June 01, 2016 - Current areas of emphasis include building resilience and joy in practice . … A past PSNet interview with the director of the Patient Safety Center for the Duke University Health … System discussed the importance of resilience. … July 24, 2019 The Patient Safety Leadership Academy at the University of Pennsylvania … July 10, 2019 Prevalence and Economic Burden of Medication Errors in the NHS England.

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