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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - with SUDs in Project Nurture to patients with SUDs in the rest of Medicaid (n = 114 and n = 507, respectively … with them in a way that aligns with the messaging and intent of the program. … The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter
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psnet.ahrq.gov/issue/contribution-diagnostic-errors-maternal-morbidity-and-mortality-during-and-immediately-after
February 17, 2021 - This issue brief explores the role of diagnostic error in maternal morbidity and mortality , the preventability … of common problems such as maternal hemorrhage , and the importance of multidisciplinary efforts to … : State of the Science. … Perinatal Safety Culture to Improve Equitable Maternal Healthcare Delivery and Outcomes. … maternal morbidity and mortality in the United States.
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - Elizabeth Salisbury-Afshar: There is absolutely stigma in health care against people who use substances … We live in a society where health care is mostly paid for by employers, so some folks are nervous to … Past negative experiences in health care make people very hesitant to go back. … Sometimes that means taking health care out of the clinic, and sometimes it means bringing harm reduction … General Public
Hospitals
Health Care Providers
Health Care Executives and Administrators
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psnet.ahrq.gov/issue/instruments-and-warning-signs-identifying-and-evaluating-frequency-adverse-events
July 20, 2022 - Instruments and warning signs for identifying and evaluating the frequency of adverse events in intermediate … Same Author(s)
Assessment of changes in visits and antibiotic prescribing during the Agency … November 28, 2012
Enabling a learning healthcare system with automated computer protocols … support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network … January 25, 2023
Healthcare-associated adverse events in alternate level of care patients
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - health care but they are subject to many safety threats. … JB : So much of health care is about communication and about making sure that we hear what the patient … going to somebody's house, providing health care, and keeping them out of the health care system or … the best health care. … Health Care Providers
Educators
Policy Makers
Emergency Medicine
View More
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 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 … The presence of blood clots in the stool decreases the likelihood of upper GIB.( 9 ) However, in some … a psychological resilience intervention for health care workers during the COVID-19 pandemic
October … Topic
Hospitals
Health Care Providers
Gastroenterology
Diagnostic Errors
Transfusion
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - By nature, the health care setting is inherently stressful, often chaotic, and frequently a source of … To meet the literacy needs of diverse populations, health care systems and providers should practice … In the same day surgery setting, it is important that the health care team have a reliable process in … approaches that can enhance the quality and safety of our health care system. … SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - EMS personnel provide care outside of a healthcare facility in complex environments. … Int J Qual Health Care . 2021 Feb 5;33(1):mzab013. doi:10.1093/intqhc/mzab013. … all parts of the healthcare continuum experience this the same but we're able to compare them with a … In healthcare, that would be something like, if I noticed that these two bottles of medication come in … of a culture of safety in the EMS setting.
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psnet.ahrq.gov/issue/effects-multifaceted-medication-reconciliation-quality-improvement-intervention-patient
April 12, 2023 - The study highlights the difficulty inherent in implementing quality improvement interventions in real-world … A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices … September 9, 2013
Implementation of the I-PASS handoff program in diverse clinical environments … November 16, 2022
Effect of pharmacist counseling intervention on health care utilization … February 15, 2017
Health-care providers want patients to read medical records, spot errors
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - Unfortunately, it was not until the patient had a fall in the ED that the healthcare team ordered the … for Healthcare Research and Quality (AHRQ) has reinforced the importance of identifying and addressing … July 13, 2016
Assessment of fidelity in interventions to improve hand hygiene of healthcare … February 28, 2024
Impact of hospital accreditation on quality improvement in healthcare … analysis of communication errors in health care.
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - care delivery process. … care during pediatric transfers, enhance family- and patient-centered care, and improve clinical outcomes … Family-centered care: current applications and future directions in pediatric health care. … a health care system with an advanced electronic medical record. … November 16, 2022
Seroprevalence of SARS-CoV-2 among frontline health care personnel
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psnet.ahrq.gov/issue/electronic-health-record-nudges-and-health-care-quality-and-outcomes-primary-care-systematic
March 09, 2022 - Review
Electronic health record nudges and health care quality and outcomes in primary … Electronic health record nudges and health care quality and outcomes in primary care: a systematic review … Results show nudges improve specific aspects of healthcare quality, but most studies reported only process … Electronic health record nudges and health care quality and outcomes in primary care: a systematic review … March 24, 2019
Changes in medication safety indicators in England throughout the covid
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - of Cyberattacks
Cyber attackers gain access to healthcare systems through tactics like phishing, which … https://psnet.ahrq.gov//#_edn1
https://psnet.ahrq.gov/issue/cybersecurity-patient-safety-policy-options-health-care-sector … 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. … ://psnet.ahrq.gov//#_ednref2
https://aspr.hhs.gov/cyber/Documents/Health-Care-Sector-Cybersecurity-Dec2023
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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - In recognition of the importance of this systems-based approach to safety initiatives, AHRQ created … Susan McGrath: I think the idea of having engineers be involved in healthcare system design is very … engineering approaches in healthcare. … healthcare organizations. … Hospitals
Health Care Providers
Clinical Technologists
Health Care Executives and Administrators
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psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
November 01, 2012 - 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 … He has written about the importance of humanism in medicine and has become a passionate advocate for … Alan Garber, my colleague who's now provost at Harvard, described American health care as having a menu … safety culture in medical homes: a coincidence analysis.
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psnet.ahrq.gov/perspective/patient-safety-primary-care
January 31, 2020 - safety of care received by patients in the primary care setting. … Comprehensive care transformation efforts, such as patient-centered medical homes , that include care … Absent of more thoughtful design, the exponential growth in the amount of information and data providers … The global burden of diagnostic errors in primary care. … 7, 2020
Perspective
Health Care Delivery and Pharmacists
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psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-acute-care-hospitals
October 23, 2019 - Citation Text:
Toolkit To Improve Antibiotic Use in Acute Care Hospitals Agency for Healthcare Research … Elements of the process center on diagnosis, testing, reassessment and duration. … April 17, 2019
Overview of the Environmental Scan of Primary Care-Based Effort To Reduce … November 25, 2020
Adverse medication events related to hospitalization in the United … of Care.
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - Despite the importance of RCA, its implementation in health care can be challenging. 1 RCA effectiveness … Given the vast number and variety of incidents in health care, RCA 2 provides detailed guidance on … The challenges of undertaking root cause analysis in health care: a qualitative study. … In health care, RCA is a regulatory process. … In health care, we can think about the design of the processes that our staff use daily and how we can
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psnet.ahrq.gov/issue/effectiveness-pharmacist-intervention-reduce-medication-errors-and-health-care-resources
August 04, 2021 - Review
Effectiveness of pharmacist intervention to reduce medication errors and health-care … Effectiveness of Pharmacist Intervention to Reduce Medication Errors and Health-Care Resources Utilization … Effectiveness of Pharmacist Intervention to Reduce Medication Errors and Health-Care Resources Utilization … to speak up in healthcare settings. … April 27, 2022
Development and usability testing of the Agency for Healthcare Research
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. … Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. … , independence and objectivity in all its CME activities to promote improvements in health care and not … He lost control in a turn and landed in the dirt on the side of the road. … Management of foreign bodies in the skin.