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Errors and Near Misses: What Health Care Could Learn From Aviation | PSNet

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September 01, 2006 - developed across many health care systems. … One of the most striking differences between health care and aviation is a bias in health care toward … Many health care systems have already made great strides forward in the complex task of improving patient … Institutional resilience in healthcare systems. Qual Health Care. 2001;10:29-32. … Now some HMOs are like us in that way, and other countries' health care systems run much like the VA.

Chest Pain in a Rural Hospital | PSNet

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June 02, 2021 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … ).( 2 ) However, because of the large number of rural EDs, 42% of all ED visits in the US occur at EDs … In most cases, patients physically present in the ED are the responsibility of the ED provider. … The importance of cognitive errors in diagnosis and strategies to minimize them. … March 11, 2020 Microsystems in health care: Part 2.

Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement in safety. | PSNet

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January 11, 2023 - March 28, 2012 Observational evidence of the prevalence and association of polypharmacy … September 25, 2019 Engaging the patient and family in the surgical safety process utilizing … of multiple perspectives. … February 22, 2019 Patient groups, clinicians and healthcare professionals agree—all test … Health Care Providers Information Professionals Medicine Epidemiology of Errors and Adverse

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center. | PSNet

psnet.ahrq.gov/issue/interprofessionalinterdisciplinary-teamwork-during-early-covid-19-pandemic-experience

September 23, 2020 - to COVID-19 response, and highlights the importance of leadership , broad inclusion, transparent decision-making … September 23, 2020 Seroprevalence of SARS-CoV-2 among frontline health care personnel … June 3, 2020 Effect of delays in the 2-week-wait cancer referral pathway during the COVID … November 18, 2020 Bracing for the storm: one health care system's planning for the COVID … and healthcare workers safe.

Maternal Safety and Perinatal Mental Health | PSNet

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March 28, 2023 - Preventive Services Task Force have recognized the importance of appropriate mental healthcare throughout … Patients should be educated on the importance of seeking help and the available resources and support … This fact highlights the importance of considering the mental health needs of both parents in perinatal … the current tools we have in our healthcare system. … move the needle somehow when we are in this fragmented healthcare system.

Parents' perspectives on "keeping their children safe" in the hospital. | PSNet

psnet.ahrq.gov/issue/parents-perspectives-keeping-their-children-safe-hospital

June 27, 2018 - in health care. … of their children in the hospital setting. … patients, health professionals and healthcare organizations. … November 21, 2016 Perspective The Role of the Patient in … Topic Hospitals Health Care Providers Family Members and Caregivers Pediatrics Psychological

Diagnostic discordance, uncertainty, and treatment ambiguity in community-acquired pneumonia: a national cohort study of 115 U.S. Veterans Affairs hospitals. | PSNet

psnet.ahrq.gov/issue/diagnostic-discordance-uncertainty-and-treatment-ambiguity-community-acquired-pneumonia

June 07, 2023 - This study highlights the importance of understanding diagnostic uncertainty in pneumonia-related care … June 7, 2023 Enabling a learning healthcare system with automated computer protocols … July 10, 2024 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a … December 16, 2020 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … Small Bowel Obstruction in the Setting of Previous Abdominal Operations February 26, 2025

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature. | PSNet

psnet.ahrq.gov/issue/perioperative-team-based-morbidity-and-mortality-conferences-systematic-review-literature

November 29, 2023 - November 29, 2023 Redeployment of health care workers in the COVID-19 pandemic: a qualitative … February 20, 2019 Factors associated with the use of cognitive aids in operating room … in the operating room. … September 14, 2022 The evolution of the Anesthesia Patient Safety Movement in America … January 26, 2022 The nature of reported safety events related to care coordination in

In Conversation With... Remle P. Crowe, PhD | PSNet

psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd

May 16, 2022 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … 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 … 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.

Lessons learned from a systems approach to engaging patients and families in patient safety transformation. | PSNet

psnet.ahrq.gov/issue/lessons-learned-systems-approach-engaging-patients-and-families-patient-safety-transformation

February 12, 2020 - This article describes lessons learned during the six years after a large regional health care system … in the U.S. established a systemwide infrastructure of patient and family advisory councils (PFACs) … February 12, 2020 Communication with patients and families regarding health care-associated … healthcare staff in the United Kingdom and Australia. … August 31, 2022 Identifying and encouraging high-quality healthcare: an analysis of the

Getting the Diagnosis Both Right and Wrong | PSNet

psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong

May 29, 2024 - in health care, although to-date, few, if any, of these have been focused on diagnostic performance … Since existing programs focused on teamwork are already well-rooted in many health care systems and health … addition to other aspects of health care. … Improving Diagnosis in Health Care. … Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine

What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. | PSNet

psnet.ahrq.gov/issue/what-do-we-really-know-about-crew-resource-management-healthcare-umbrella-review-crew

September 29, 2021 - What do we really know about crew resource management in healthcare? … Crew resource management (CRM), originally developed in aviation, has become popular in healthcare as … What do we really know about crew resource management in healthcare? … in health-care professionals' education. … March 7, 2012 A systematic review of the effect of telepharmacy services in the community

Double Trouble | PSNet

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August 01, 2012 - the geriatric patient, (ii) the importance of anticipating confusion from sound-alike medications, ( … iii) the responsibility of the health care team to provide careful instructions to patients about their … in care between different health care settings—in this instance, discharge from hospital to home. … health care system.”( 5 ) Medication reconciliation is particularly important at the time of hospital … with a mission to provide error-reduction strategies to the health care community, policy makers, and

Medication management strategies by community-dwelling older adults: a multisite qualitative analysis. | PSNet

psnet.ahrq.gov/issue/medication-management-strategies-community-dwelling-older-adults-multisite-qualitative

November 20, 2024 - Several strategies were in opposition to the guidelines, including self-weaning or splitting pills. … goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare … November 20, 2019 Implementation of a parent-centered approach to the preinduction checklist … April 12, 2023 The source of purchased medications and its impact on medication mistakes … March 16, 2022 Medicine self-administration errors in the older adult population: a systematic

The Unintended Consequences of Florida Medical Liability Legislation | PSNet

psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation

February 01, 2003 - Large academic health care centers like the University of Miami paid more than $40 million in 2004 on … law, but damage to the health care system had been done. … societal-political issues of redesigning health care systems to make them safer while making them more … health care system. … The untoward consequences of well-intentioned Florida legislation have crippled the health care system

Patient Safety in Frail Older Patients | PSNet

psnet.ahrq.gov/perspective/patient-safety-frail-older-patients

November 26, 2019 - the healthcare system, including hospital stays. 2 The presence of multiple chronic conditions increases … the effects of unsafe healthcare conditions. … A systematic review of the literature. Int J Qual Health Care . 2013;25(5):542-54. 2. … Frailty syndrome: Implications and challenges for health care policy. … July 12, 2023 Patient safety in home health care: a grounded theory study.

The Deadly Duo | PSNet

psnet.ahrq.gov/web-mm/deadly-duo

April 28, 2021 - The Commentary The delivery of mental health care by primary care physicians is likely a necessary … component of health care in the United States. … Of note, fatality before reaching a health care facility occurs in approximately 70% of patients attempting … Yet only 2% to 3% of TCA overdose cases that reach a health care facility result in death.( 23 ) Factors … Treating major depression in primary care practice: an update of the Agency for Health Care Policy and

Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. | PSNet

psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures

August 31, 2022 - , independence and objectivity in all its CME activities to promote improvements in health care and not … any entity producing, marketing, re-selling, or distributing health care goods or services consumed by … Learning Objectives Describe how health care providers should evaluate acute neurological deficits of … Finally, this case highlights the importance of a team approach involving serial neurologic assessment … infection reduction and health care cost savings.

Long-term Care and Patient Safety | PSNet

psnet.ahrq.gov/primer/long-term-care-and-patient-safety

February 24, 2022 - Although this group of organizations are not considered health care facilities, they do provide some … And, while there has been a significant decline in nursing home admissions, health care utilization after … patient safety (such as the proportion of patients who experience a health care–associated infection … The accreditation process emphasizes the importance of patient safety and efforts to prevent hospital … While these efforts are all important, fundamental health care system issues such as adequate staffing

Medication Reconciliation Pitfalls | PSNet

psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls

May 01, 2006 - Process Variation The health care professionals in this case failed to accurately review and document … Allowing for at least two health care professionals in verifying the identity, dosage, and instructions … This case emphasizes the importance of including pharmacists in review of home medication. … health care professional and made available across all patient encounters. … Topic Intensive Care Units Emergency Departments Health Care Providers Risk Managers

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