AHRQ Search | Home Page

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error | PSNet

psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error

July 30, 2020 - healthcare system faces increased pressure to diagnose cases rapidly and accurately. 6 This primer has … older adults and people with disabilities in the United States has highlighted the importance of conscious … Disability, ethics, and health care in the COVID-19 pandemic. … Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes … February 9, 2012 Seroprevalence of SARS-CoV-2 among frontline health care personnel in

Despite Clues, Failed to Rescue | PSNet

psnet.ahrq.gov/web-mm/despite-clues-failed-rescue

August 02, 2015 - As Reason's Swiss Cheese Model of failure ( 1 ) demonstrates, major errors can occur in health care settings—including … Designing a clear, evidence-based approach that can be integrated into a health care delivery system … approach to health care system organization and design. … Importance of teamwork, communication and culture on failure-to-rescue in the elderly. … Care Units Health Care Providers Cardiology Failure to rescue Active Errors View

Failure to Rescue the Mother | PSNet

psnet.ahrq.gov/web-mm/failure-rescue-mother

September 23, 2020 - importance of preoperative antibody identification. … Improving Health Care Response to Obstetric Hemorrhage, Version 2.0: A California Toolkit to Transform … From the Same Author(s) Seroprevalence of SARS-CoV-2 among frontline health care personnel … January 12, 2022 Enabling a learning healthcare system with automated computer protocols … Topic Labor and Delivery Health Care Providers Obstetrics Nonsurgical Procedural Complications

In Conversation With… J. Bryan Sexton, PhD, MA | PSNet

psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma

February 26, 2025 - BS : At the Patient Safety Center, we work with a lot of different health care systems and many of them … I don't think that that was a misstep, but going forward, patient-centered care requires a high level … of resilience in our health care workers (people-centered care). … As patient-centered care is our goal, we have to do much more deliberate work for health care workers … The reason that's complicated in terms of building resilience is because health care workers are just

In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point

September 24, 2024 - Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare articulates the importance of establishing … of the hospital system communicating safety priorities and the importance or promoting safety in team … Alternatively, a “Safety II” approach sees healthcare delivery as non-linear, and complex, so repeatable … Zero harm in health care. NEJM Catalyst . 2020;1(2). [Available at] Davis DJ. … Topic General Public Hospitals Health Care Providers Health Care Executives and Administrators

Order Interrupted by Text: Multitasking Mishap | PSNet

psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap

August 21, 2015 - Appreciate the risks of using mobile devices in health care settings. … List best practices and policies for using mobile devices in health care. … The potential benefits of mobile devices in health care are many. … One last positive side effect of using personal mobile devices in health care is that providers are likely … Mobile Applications in Health Care.

Delay in Initiating Antibiotics Results in Fatal Error | PSNet

psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error

August 02, 2015 - problem solving must be addressed from the perspective of the individual, the program, and the health … care system. … The third role of the program director is to serve as a liaison between the program and the health care … system. … Emergency Departments Health Care Providers Facility and Group Administrators Educators Emergency

Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement | PSNet

psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement

February 23, 2022 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … of the CVC was in agreement between ultrasound and chest x-ray in 98.9% of cases, with ultrasound offering … the use of ultrasound guidance during central line insertion, 9 included in its Making Health Care … InMaking Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices … The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise

Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care. | PSNet

psnet.ahrq.gov/issue/telemedicine-ensuring-safe-equitable-person-centered-virtual-care

March 29, 2006 - March 29, 2006 The aspects of healthcare quality that are important to health professionals … Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior … COVID-19 pandemic by using a human factors approach: a leap into the future of health care delivery? … Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome. … August 19, 2020 View More See More About The Topic Health Care Executives

Patient Engagement and Safety | PSNet

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

August 30, 2023 - As articulated in the seminal Institute of Medicine report Crossing the Quality Chasm , such patient-centered … care should be "respectful of and responsive to individual patient preferences, needs, and values and … The Joint Commission mandated that health care organizations "encourage patients' active involvement … The Agency for Healthcare Research and Quality's Questions Are the Answer program and 20 Tips to Help … The Agency for Healthcare Research and Quality and the World Health Organization sponsor a variety of

The Role of the Patient in Improving Patient Safety | PSNet

psnet.ahrq.gov/perspective/role-patient-improving-patient-safety

March 01, 2007 - health care organization. … A second role for patients and family members is in working to improve safety and quality in health care … Silence Kills: The Seven Crucial Conversations in Healthcare. … , or do something for kids in the health care setting. … More About The Topic Hospitals Health Care Providers Health Care Executives and Administrators

How can interventions more directly address drivers of unprofessional behaviour between healthcare staff? | PSNet

psnet.ahrq.gov/issue/how-can-interventions-more-directly-address-drivers-unprofessional-behaviour-between

October 09, 2024 - This paper underlines the importance of mapping the individual drivers of unprofessional behavior to … August 26, 2020 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … medical center’s corrective action plan in response to fatal medication error using the Institute for … healthcare staff in the United Kingdom and Australia. … March 8, 2023 National patient safety goal to improve health care equity.

In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring | PSNet

psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring

March 15, 2023 - At times, patients will want to please their health care provider, and with the pen and paper method … Neal Sikka : In 2012, our team was awarded a Health Care Innovation Award by the Centers for Medicare … Eventually some of that data could become connected into the healthcare system more tightly. … delivery of healthcare through electronic communication, or telehealth , has changed greatly since … Health care: Telehealth and remote patient monitoring use in the Medicare and selected federal programs

Mismanagement of Delirium | PSNet

psnet.ahrq.gov/web-mm/mismanagement-delirium

February 13, 2014 - 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 … care organizations and providers ensure patients and families are encouraged to participate in care … One-year health care costs associated with delirium in the elderly population. … Committee on Quality of Health Care in America, Institute of Medicine.

Enhancing patient safety: a national standard for cyber resiliency in healthcare. | PSNet

psnet.ahrq.gov/issue/enhancing-patient-safety-national-standard-cyber-resiliency-healthcare

September 23, 2020 - This article describes the development of a new standard to support cyber resiliency in Canada’s healthcare … system. … importance of cyber incident response planning. … Same Author(s) Seroprevalence of SARS-CoV-2 among frontline health care personnel in a … July 22, 2020 Artificial Intelligence in Health Care: The Hope, the Hype, the Promise

Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis | PSNet

psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis

October 28, 2020 - Case Objectives Realize the importance of early sepsis diagnosis and treatment. … , resulting in an estimated $24 billion in costs each year to the health care system.( 4 ) Reacting … Presenting symptoms independently predict mortality in septic shock: importance of a previously unmeasured … Author(s) Health care-associated infections among critically ill children in the US, 2013 … October 21, 2020 Communication with health care workers regarding health care-associated

Equity in Patient Safety | PSNet

psnet.ahrq.gov/perspective/equity-patient-safety

September 24, 2024 - the healthcare system, directly linking inequitable care to patient safety. 1 Resolving this inequity … marginalized groups are sometimes viewed socially, as problems beyond the scope of healthcare systems … that have been made vulnerable by health care and other systems as accurately as in white patients. … The checklist also enabled identification of areas in the healthcare delivery infrastructure in which … J Health Care Poor Underserved . 2010;21(3):879-897. doi:10.1353/hpu.0.0323 Meadows AR, Byfield R,

The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Monitoring. | PSNet

psnet.ahrq.gov/issue/definition-quality-and-approaches-its-assessment-vol-1-explorations-quality-assessment-and

May 24, 2015 - Quality and safety are ultimately determined by the degree to which health care improves important patient … In this first volume, Donabedian develops the framework for measuring quality by assessing elements of … for quality measurement in health care. … October 20, 2023 High-Performance Work Systems in Health Care Management: Parts 1-5. … February 19, 2020 Challenges and opportunities from the Agency for Healthcare Research

Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement

September 24, 2024 - Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare articulates the importance of establishing … Zero harm in health care. NEJM Catalyst . 2020;1(2). [Available at] Davis DJ. … But in health care right now I would argue we don't have the means to have zero preventable harm. … There are some processes in health care that we can map out in linear steps. … The hard work of health care transformation. N Engl J Med . 2016;375(8):709-711.

Care Transitions | PSNet

psnet.ahrq.gov/perspective/care-transitions

December 01, 2007 - Other aspects of the health care system also present barriers to an effective transfer of care. … , with quality officers at leading health care delivery systems, and with some of the nation's health … know health care delivery backwards and forwards—are themselves not immune from seeing these issues fall … care delivery venues. … , for example, in an integrated health care system, if this prevents patients bouncing back to hospitals

Search AHRQ

Results