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psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - Additionally, he serves as the Director of the Texas Center for Oral Healthcare Quality and Safety. … on using informatics approaches to improve the safety and quality of oral healthcare. … quality of oral health care. … When you go to an oral health care provider, they will examine you and say, you need this procedure ( … needs to be done, the importance, and the willingness and interest to spend time and money on it.
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psnet.ahrq.gov/issue/clinical-pharmacists-and-inpatient-medical-care-systematic-review
September 09, 2013 - None of the studies demonstrated a worse overall outcome, and only one suggested increased health care … March 27, 2013
Implementation of the I-PASS handoff program in diverse clinical environments … May 8, 2017
Effect of pharmacist counseling intervention on health care utilization following … safety and medication cost of the elderly people living in a nursing home: a before-after study. … February 12, 2020
The impact of pharmacists-led medicines reconciliation on healthcare
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - AHRQ PSNet Editorial Team from the AHRQ Health Care Innovations Exchange . … This particular innovation was identified by the Editorial Team as one of continued interest and importance … Older home health care clients often take multiple medications. … A model for improving medication use in home health care patients. … among older adults receiving home health care.
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psnet.ahrq.gov/issue/evaluation-association-between-hospital-survey-patient-safety-culture-hsops-measures-and
December 21, 2017 - Programs to prevent health care–associated infections (HAIs) have been some of the most prominent successes … of the patient safety movement. … coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States. … healthcare institutions. … July 21, 2010
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Hospitals
Health Care
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - ability of health care leaders to enable practitioners to work together effectively and manage the increasingly … Books and articles attesting to the importance of patient safety culture in health care are now plentiful … In contrast, health care leaders can undermine their ability to affect lasting change and create a learning … A common complaint among health care professionals is that there is "never enough time to work on culture … Topic
Hospitals
Health Care Executives and Administrators
Organizational Behaviorists
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psnet.ahrq.gov/issue/creating-integrated-patient-safety-team
January 04, 2017 - of a patient safety team, including the key players and their roles, how to effectively integrate the … They conclude by emphasizing the importance of a commitment from organizational leadership. … results in a large health care network. … August 1, 2009
The role of teamwork in the professional education of physicians: current … January 30, 2005
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Health Care Providers
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - EHR.( 4 ) Given the fragmentation of the health care system and the increasing use of community and … community health care settings as well. … Such seamless interoperability does exist, but usually within vertically integrated health care systems … health care preferences and how to ensure those wishes can easily be transmitted across health care … CC1-03: Documentations of advanced health care directives in the electronic health records: where are
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - It now appears clear that
during the 1990s and 2000s, the health care system promoted the overuse of … adverse events and deaths occur outside health care settings. … The Agency for Healthcare
Research and Quality's Effective Health Care Program completed three reports … www.research.va.gov/topics/pain.cfm
https://psnet.ahrq.gov/issue/association-between-opioid-tapering-and-subsequent-health-care-use-medication-adherence-and … https://psnet.ahrq.gov/issue/association-between-opioid-tapering-and-subsequent-health-care-use-medication-adherence-and
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - they have failed to appreciate and account for the complexity of patients and health care processes … work of health care; and the cognitive load created by the poor usability 6 of current systems. … Several resources are available to assist health care organizations in this effort. … SAFER guides are designed for use in all types of health care settings. … May 8, 2019
A Crisis in Health Care: A Call to Action on Physician Burnout.
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - , 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 … control of the physician or the healthcare system
System-related errors, which include technological … Finally, all healthcare delivery systems should have systems in place to ensure that all patients receive … Free full text
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 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 … centralize stroke care in the United States.( 14 ) Various state-based agencies, the Healthcare Facilities … Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare … Hospitals
Health Care Providers
Neurology
Medical Complications
Active Errors
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psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - Communication issues among the health care team are the subject of improvement projects and interprofessional … , or by an admitting health care provider) to mention her pregnancy to providers at each point of contact … Data show that health care team involvement, in addition to CPOE, is important to preventing medication … errors because health care providers often override electronic alerts.( 14,15 ) In the end, it was … The current FDA categories for medication use in pregnancy may not fit all of health care providers'
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - 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 … Agency for Healthcare Research and Quality (AHRQ), U.S. … Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Departments
Operating Room
Health Care Providers
Nurses
Emergency Medicine
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services … Health care is remarkable for its interdependencies across personnel. Think of this PICU. … Because of the massive production pressure, health care workers feel uncomfortable raising an alarm when … Qual Saf Health Care. 2004;13(suppl 1):i72-i79. [ go to PubMed ] 3. … Qual Saf Health Care. 2003;12:112-118. [ go to PubMed ] Figure Figure.
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psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
August 31, 2020 - Medical Center (GBMC) provide three different examples of how healthcare systems have expanded their … They think there is an opportunity for a recalibration, or restructuring, of UCD’s healthcare delivery … IDHI: I think that in a traditional model, like in the University of Arkansas or other healthcare systems … Care Delivery and Pharmacists During the COVID-19 Pandemic
June 29, 2020 … COVID-19 pandemic by using a human factors approach: a leap into the future of health care delivery?
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - Susan McGrath: I think the idea of having engineers be involved in healthcare system design is very … engineering approaches in healthcare. … healthcare organizations. … In recognition of the importance of this systems-based approach to safety initiatives, AHRQ created … Hospitals
Health Care Providers
Clinical Technologists
Health Care Executives and Administrators
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psnet.ahrq.gov/issue/ahrq-patient-safety-project-reduces-bloodstream-infections-40-percent
January 22, 2020 - units (ICUs) in Michigan stands as one of the landmark accomplishments of the patient safety field. … The Agency for Healthcare Research and Quality subsequently sponsored an effort to extend the success … factors and health care clinician behaviors. … a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. … Health Care Providers
Health Care Executives and Administrators
Critical Care
Infectious Diseases
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Review the drivers of speaking up in the health care environment. … Bryan Sexton, PhD
To assess or improve safety culture in health care is to assess or improve "the way … Exquisite teamwork, leadership, and communication are required for things to go well in the health care … the health care environment. … for the underlying importance of workforce well-being.
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psnet.ahrq.gov/issue/coronavirus-disease-2019-covid-19-pandemic-central-line-associated-bloodstream-infection
June 22, 2022 - December 16, 2020
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated … infections in 2020: a summary of data reported to the National Healthcare Safety Network. … May 18, 2022
Health care safety during the pandemic and beyond--building a system that … February 2, 2022
Impact of full personal protective equipment on alertness of healthcare … Care Units
Health Care Executives and Administrators
Critical Care
Public Health
View
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psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation-project
July 20, 2022 - This article focuses on the implementation of AHRQ’s Safety Program for Improving Antibiotic Use in … Participating hospitals reported the evidence-based content was helpful in raising awareness of the importance … Same Author(s)
Assessment of changes in visits and antibiotic prescribing during the Agency … July 10, 2017
Enabling a learning healthcare system with automated computer protocols … health care settings.