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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - Little is known about optimal strategies for clinicians and health care systems to receive feedback on … .( 7 ) In addition to increasing federal research funds for study of diagnostic errors, health care systems … Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care. … The importance of that is that health care organizations are very familiar with process improvement. … Not a single health care organization in the country or in the world is measuring the incidence of error
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psnet.ahrq.gov/issue/reducing-readmission-academic-medical-center-results-pharmacy-facilitated-discharge
August 04, 2021 - Same Author(s)
Enabling a learning healthcare system with automated computer protocols … August 9, 2023
Virtual urgent care quality and safety in the time of Coronavirus. … involvement in the transitional care of high-risk patients through medication reconciliation, medication … May 19, 2010
The effect on medication errors of pharmacists charting medication in an … Health Care Executives and Administrators
Hospital Medicine
Hospital Pharmacy
View
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psnet.ahrq.gov/issue/charter-physician-well-being
May 25, 2016 - This commentary describes a charter for health care organizations to prioritize physician well-being … A related editorial emphasizes the importance of the physician–patient relationship in creating meaning … April 5, 2013
Enabling a learning healthcare system with automated computer protocols … topic in healthcare quality, patient safety, person-centeredness and human resource management. … September 29, 2017
The Charter on Professionalism for Health Care Organizations.
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - effects of an opioid
overdose.2 In 2018, the U.S. … One strategy to aid healthcare professionals in achieving important clinical interventions is to use … use of opioids for the treatment of chronic pain, resulting in some unintended
consequences. … Healthcare systems and providers should use multi-layered education to inform patients about
appropriate … naloxone use.14,15
Individual providers and healthcare systems need to do a better job of identifying
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - , independence and objectivity in all its CME activities to promote improvements in health care and not … Understand the importance of early management of obstetric hemorrhage. … Recognize the importance of standardized protocols and built-in alerts to help to address staggering … as many health care personnel as possible who were involved in the event. … Health care providers must continuously evaluate the patient’s hemorrhage risk throughout the labor and
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - 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 … Qual Health Care. 1995;4:80-89. [go to PubMed] 3. Reason JT. … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … June 1, 2011
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Operating Room
Health
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - Health care organizations were introduced to this accident investigation technique in the mid-1990s. … In health care, errors are seen as character flaws. … To achieve a highly reliable and safer health care system, we need a hospitable soil where the seeds … Catonsville, MD: Office of Health Care Quality, Department of Health & Mental Hygiene; December 2007. … What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - population, in light of the often atypical presentation of infection and sepsis in older patients, the … Improving Diagnosis in Health Care. … Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine … August 20, 2018
Seroprevalence of SARS-CoV-2 among frontline health care personnel in … Health Care Providers
Pathology and Laboratory Medicine
Infectious Diseases
Diagnostic Test
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - The biggest information repository in health care sits in the heads of all the clinicians that you work … He has conducted and coordinated research on policies relating to public health, health care delivery … integrate teamwork principles into health care systems. … quality of health care. … a $3 trillion health care system with 800,000 physicians and 5,000 plus hospitals.
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - 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 … It can occur sporadically or in the context of the Tuberous Sclerosis Complex (TSC). … The mTOR pathway is active in a significant percentage of human cancers. … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services
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psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - Information on other types of health care–associated infections (HAIs) may be found in the Health Care–Associated … prevention of SSIs (and HAIs in general) has benefited from the development of standard metrics that … Current Context SSI prevention is a high-priority goal for health care organizations. … The Joint Commission includes use of guidelines to prevent health care-associated infections, including … Picks
The burden of healthcare utilization, cost, and mortality associated with select surgical
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psnet.ahrq.gov/issue/communication-matters-when-it-comes-adverse-events-associations-adverse-events-during-implant
December 15, 2021 - View more articles from the same authors. … Trust between patients and providers is essential to safe , effective healthcare. … Same Author(s)
The aspects of healthcare quality that are important to health professionals … April 1, 2020
Factors affecting patient safety culture among dental healthcare workers … Operating Room
Health Care Providers
Dentistry
Surgery
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psnet.ahrq.gov/issue/impact-rudeness-medical-team-performance-randomized-trial
April 24, 2018 - February 16, 2011
Unacceptable behaviours between healthcare workers: just the tip of … victim symptoms in the aftermath of a patient safety incident and association with the level of patient … harm: a cross-sectional study in the Netherlands. … May 1, 2019
Importance of safety climate, teamwork climate and demographics: understanding … May 6, 2015
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Hospitals
Health Care
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - And do they know the importance of quality indicators? Absolutely. … system. … 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 … Topic
Researchers
General Public
Hospitals
Health Care Providers
Health Care Executives
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - infant mortality. 15 Overuse of cesarean deliveries also increases cost to the healthcare system. 16 … the vaginal birth initiative: The California Health Care Foundation (CHCF) Yellow Chair Foundation HRSA … California Department of Health Care Services (the Medicaid agency), and a variety of community groups … Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter … Labor and Delivery
Health Care Providers
Physicians
Nurses
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psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - 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 … this commentary, this framework will be discussed in the context of the two cases of headache presented … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services
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psnet.ahrq.gov/issue/effects-shift-length-quality-patient-care-and-health-provider-outcomes-systematic-review
May 18, 2022 - Given the increase in shift work in health care, the authors advocate for greater study of these issues … and the importance of understanding their context in different clinical settings. … October 19, 2022
Burnout in the nursing home health care aide: a systematic review. … August 20, 2018
Seroprevalence of SARS-CoV-2 among frontline health care personnel in … interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.
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psnet.ahrq.gov/issue/towards-diagnostic-excellence-academic-ward-teams-building-conceptual-model-team-dynamics
August 20, 2018 - team dynamics in the diagnostic process. … February 7, 2024
Seroprevalence of SARS-CoV-2 among frontline health care personnel in … among older adults receiving home health care. … coordination reported in a national study of older US adults. … February 7, 2024
Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - one's own needs and self-care that ensures the physical and emotional well being of the health care … member (including attending physicians) is important to a safe and patient-centered health care system … High-reliability health care systems must balance workload with time off to ensure the physical and emotional … Preventing burnout is the responsibility of all physicians and of the health care organization in which … Topic
Hospitals
Health Care Providers
Health Care Executives and Administrators
Organizational
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Describe the importance of understanding the nature of the acute pain and its relationship to the chronic … therapy consume a disproportionate share of health care resources, including significantly more emergency … adverse opioid-related health care events. … Topic
Hospitals
Health Care Providers
Medicine
Opiates/Narcotics
Latent Errors