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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - errors, surgical complications, and health care–associated infections. … of a committee at the Institute of Medicine on Diagnostic Error in Health Care, which will produce a … This study highlights the importance of availability bias. … The year 2014 saw one notable report of how two separate health care organizations addressed such system … Topic
Hospitals
Health Care Executives and Administrators
Medicine
Diagnostic Errors
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - https://psnet.ahrq.gov/primer/health-care-associated-infections
PSNet primers are regularly reviewed … More
than one million HAIs occur across the United States healthcare system every year. … -2023-analysis-23970-reports
https://psnet.ahrq.gov/issue/health-care-associated-infections-meta-analysis-costs-and-financial-impact-us-health-care … According to data reported to the National Healthcare Safety Network, the incidence
of healthcare-associated … the recommended methods as standard practice in healthcare delivery organizations.
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - 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 … They had an encounter with the health care system. … RW : Do you think the health care system is set up to manage this problem? … RW : What do you think the lessons are from this sad story for the health care system and for the field
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - placing tremendous stress on local healthcare systems and associated workforces. … for healthcare systems. … A study of healthcare providers and hospital staff in the Hunan province of China found that explicit … the healthcare system. 6-7 The strategies highlighted herein build on foundational patient safety … keeping patients and healthcare providers safe in the age of COVID-19.
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - , 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 … Other aspects of the health care system also present barriers to an effective transfer of care.
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medicine in the Division of … majority of antimicrobial expenditures were in the outpatient sector/healthcare setting. … in implementing antibiotic stewardship in outpatient healthcare settings. … Another big barrier is that dentists, in general, do not have access to your healthcare data.
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psnet.ahrq.gov/perspective/accountability-patient-safety
January 01, 2018 - a framework of a just culture that incorporates appropriate accountability in health care. … For example, failing to perform hand hygiene demonstrably leads to health care–associated infections, … With the growing focus on patient-centered care, the concept of emotional harm is likely to garner more … meetings in 2016, including the American College of Healthcare Executives Congress on Healthcare Leadership … Topic
Hospitals
Health Care Executives and Administrators
Medicine
Psychological and
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - model of healthcare that predates the pandemic and aims for better connection of the patient with their … who is a member of a healthcare delivery team with six core roles: patient education, staff mentoring … And do they know the importance of quality indicators? Absolutely. … system. … Topic
Researchers
General Public
Hospitals
Health Care Providers
Health Care Executives
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - he is generally acknowledged as one of the foremost experts and leaders in health care quality and patient … One is that so much of trying to work in health care today is working under outside pressure. … or concern expressed by the health care professional, patient, or, in some cases, family members.( 1 … and skills in critical care medicine, to the bedside of patients throughout a hospital or health care … health care delivery.
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psnet.ahrq.gov/issue/could-emotional-intelligence-make-patients-safer
October 29, 2017 - February 14, 2017
Seroprevalence of SARS-CoV-2 among frontline health care personnel … September 23, 2020
Enabling a learning healthcare system with automated computer protocols … May 11, 2022
Tiered daily huddles: the power of teamwork in managing large healthcare … July 3, 2016
Understanding psychological safety in health care and education organizations … January 28, 2015
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Hospitals
Health
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … the 10 questions are weighted based on importance, and the summated score for each medication is then … To successfully implement deprescribing practices in clinical settings, the Institute for Healthcare … Throughout each step of the implementation process, the IHI Deprescribing Guideline stresses the importance … Care Providers.
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - The clinicians failed to appreciate the importance of physiologic insulin replacement in patients with … of insulin in the United States. 2
Even if the patient in this case did not have DKA, the order … Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019 . … Survey of Healthcare Professionals: Inpatient Diabetes Care and Glycemic Management. … November 29, 2023
Development and usability testing of the Agency for Healthcare Research
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - record so that health care providers can easily find this information in the future. … As health care providers, we have a responsibility to ensure that the quality of health care is not sacrificed … Use online registers for anesthetic problems
Some health care systems offer online anesthetic problem … This type of online register is useful when a patient receives care in different health care systems … care systems.
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - In this case, the safety features of the ADM were bypassed on the nursing unit by the use of the portable … Most health care providers are not educated about human factors issues and the potential influence of … Moreover, health care workers often overestimate their abilities and underestimate their limitations … importance of human factors in their work will be better able to anticipate and guard against hazardous … Hassles: their importance to nurses’ quality of work life.
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psnet.ahrq.gov/innovation/catching-those-who-fall-through-cracks-integrating-follow-process-emergency-department
September 09, 2020 - The system also has a failsafe in place; if the alert is not acknowledged within 60 minutes, the hospital … Nearly all of the in-network patients with incidental findings were referred to their primary care provider … to primary care, specialty care, or a federally qualified health care clinic. … June 16, 2009
Impact of opioid administration in the intensive care unit and subsequent … and Nicole Werner, PhD
November 16, 2022
Disparate perspectives: exploring healthcare
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psnet.ahrq.gov/issue/measuring-harm-health-care-optimizing-adverse-event-review
May 15, 2013 - Study
Measuring harm in health care: optimizing adverse event review. … Measuring Harm in Health Care: Optimizing Adverse Event Review. … Determining the severity of harm or potential harm is a challenge in patient safety. … events including falls , health care–associated infections , pressure ulcers, and blood product errors … Measuring Harm in Health Care: Optimizing Adverse Event Review.
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - 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 … Interruptions and distractions in healthcare: review and reappraisal. … Qual Saf Health Care. 2010;19:304-312. [go to PubMed] 2. Silverman AT, Goldfarb MA, Baker T. … 1, 2003
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Hospitals
Health Care
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - -19, but to foster resilience and capabilities for the next unknown threat to the healthcare system. … Anjali Joseph, PhD
Professor
Spartanburg Regional Healthcare System Endowed Chair in Architecture and … Understanding the Role of Health Care Facility Design in the Acquisition and Prevention of HAIs. … I think the healthcare system during the pandemic response needed more external support. … additional bed capacity, etc., to take some of the resource pressure off of the healthcare system.
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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - health care provider. … , even among experienced health care providers.( 15 ). … that are pretty foreign to health care. … health care, and they're not. … a health care environment.
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psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
October 01, 2004 - Besides the usual advantages of simulation for training in health care ( 5 , 6 ), simulation has particular … In fact, the real questions about simulation and team training in health care are about the efficacy … Care System
References
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1. … The future vision of simulation in health care. … The use of simulation for training teamwork skills in health care: how low can you go?