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psnet.ahrq.gov/issue/hospital-error-oversight-called-lax-state-takes-too-long-investigate-mistakes-patient
May 04, 2015 - This article explores inefficiencies in the process for reporting and investigating adverse events in … September 21, 2005
Implementation and facilitation of post-resuscitation debriefing: … a comparative crossover study of two post-resuscitation debriefing frameworks. … April 1, 2024
Perspective
The Media’s Role in Patient Safety … April 27, 2022
Chasing Zero: Winning the War on Healthcare Harm.
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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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www.ahrq.gov/sites/default/files/2024-01/devine-report.pdf
January 01, 2024 - Her subjects are
the healthcare professionals who own (as is the case for physicians at The Everett … Interpreting indirect treatment comparisons and network meta-analysis for
health care decision-making … Network (SCOAP-CERTN)”
Co-Investigator (PI: Flum)
15%/18.75%/20%; $11,799,186
2010-2013 Agency for Health … Care Research and Quality (1R18 HS019531)
“Communication to Prevent and Respond to Medical Injuries … Forum of AHRQ’s Effective Healthcare Program in
October 2011.
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digital.ahrq.gov/sites/default/files/docs/medication-management-elderly-transcript-081811.pdf
June 16, 2021 - And communication errors between healthcare providers are common in the care
of older patients. … How frequently do you discuss the importance of
medications with your patients or providers, depending … times that they have discussed with their patients the importance of meds or the important
or potential … reinforce their participation in
the healthcare team. … But the most important person was them. You are the captain of the healthcare
team.
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psnet.ahrq.gov/node/49500/psn-pdf
January 01, 2006 - care systems. … Physicians’ office personnel, pharmacists, and
all health care providers play an important role in educating … In addition, highlighting (by bolding in the ingredients) the presence of acetaminophen in
combination … Agency for Healthcare
Research and Quality (AHRQ), U.S. … Readers should not interpret any statement in this report as an official position of AHRQ or
of the
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psnet.ahrq.gov/issue/identification-hospital-complications-claims-data-it-valid
June 13, 2011 - support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network … February 18, 2011
The nature of adverse events in hospitalized patients. … February 18, 2011
Enabling a learning healthcare system with automated computer protocols … October 1, 2014
Creating a high-reliability health care system: improving performance … July 27, 2018
Improving health care quality and patient safety through peer-to-peer assessment
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psnet.ahrq.gov/node/50610/psn-pdf
October 30, 2019 - in cost of care, a 21% reduction in the length of stay for the most preterm infants, and the
elimination … country and other health care settings. … Pediatrics
Division of Neonatology
Intermountain Healthcare
St. … Variation in performance of neonatal intensive care units
in the United States. … The approach
protects harm from health care workers and infants.
Figure 2.
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - the healthcare system, directly linking inequitable care to patient safety. 1 Resolving this inequity … marginalized groups are sometimes viewed socially, as problems beyond the scope of healthcare systems … that have been made vulnerable by health care and other systems as accurately as in white patients. … The checklist also enabled identification of areas in the healthcare delivery infrastructure in which … J Health Care Poor Underserved . 2010;21(3):879-897. doi:10.1353/hpu.0.0323
Meadows AR, Byfield R,
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www.ahrq.gov/news/newsletters/e-newsletter/913.html
May 01, 2024 - The other study , published in JAMA Network Open, found that the odds of in-hospital mortality for … The theme aligns with AHRQ’s ongoing efforts to address the healthcare needs of all women. … to be a problem in mental healthcare, but there is a lack of consensus on how to conceptualize, define … importance of helping patients reduce or prevent the harms of substance use. … Addressing pregnancy and parenting in mental health care: perspectives of women with serious mental illness
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www.ahrq.gov/news/newsletters/e-newsletter/936.html
November 01, 2024 - Contribute to AHRQ’s Effective Health Care Program . Explore Careers at AHRQ . … Healthcare Research program, the future of healthcare informatics, digital healthcare equity and efforts … Contribute to AHRQ’s Effective Health Care Program AHRQ encourages the public to participate in the agency … ’s Effective Health Care (EHC) Program , which conducts evidence reviews to inform healthcare decision-making … on drugs, devices, surgeries and approaches to healthcare delivery.
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
August 10, 2025 - with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the... … his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous … The commentary discusses the challenges of screening for suicide risk and the importance of continuity … The commentary discusses the importance of CT scans for evaluating spontaneous pneumothorax and educating … and physical exams and the importance of structured inter-professional handoffs and closed-loop referrals
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psnet.ahrq.gov/issue/design-and-reliability-specific-instrument-evaluate-patient-safety-patients-acute-myocardial
October 18, 2023 - tertiary hospital in the…. … In this retrospective study, researchers described the development and validation of a tool to assess … November 6, 2024
Fostering a just culture in healthcare organizations: experiences in … August 31, 2022
Diagnostic error in the emergency department: follow up of patients with … February 2, 2011
Importance of prevention and early intervention of adverse events in
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/cerner-q-a-session.pdf
June 02, 2025 - Rubins is the Medical Director of Advanced Decision Support at Mass
General Brigham Digital Healthcare … Emory Healthcare
As many of the questions were general to the process and implementation of any EHR … • As a large healthcare system, we wanted to make sure that a patient’s documentation
traveled with … At
the time that we implemented automatic referral, our healthcare system had four
hospitals and 100 … the importance of
CR.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/influenza-rsv-guide.docx
September 01, 2022 - This means that if influenza is in the community, 70 percent of adult patients coming in with acute-onset … persons at risk of developing complications from influenza, and healthcare workers who care for patients … RSV circulates in most of the United States in the fall through spring months. … In this circumstance, like in the height of influenza season, you may not need to test unless you are … Any practice described in this presentation must be applied by healthcare practitioners in accordance
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
February 09, 2005 - efficient new
tool.
4) Given the importance of local factors in clinical decision support
system … are ever “generalizable,” this observation underscores the
importance of using a mixture of methods … Acknowledgments
Funding for the project was provided by the Agency for Healthcare Quality
and Research … Decision support and safety of clinical
environments. Qual Saf Health Care 2002;11:69–75.
6. … Qual Manag Health Care 1998;6(4):15–
28.
11. McMahan D, Smith D, Carey M, et al.
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psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
June 29, 2020 - Health Care Delivery and Pharmacists During the COVID-19 Pandemic
June 29, 2020 … Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet]. … Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet]. … in the healthcare system that is expected to worsen before it improves. … Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet].
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs018171-arora-final-report-2013.pdf
January 01, 2013 - New Mexico Health Science Center (UNMHSC)
Project ECHO® (Extension for Community Health Care Outcomes … )
Federal Project Officer:
Angela Nunley
Submitted to:
The Agency for Healthcare Research … Statements in the report should not
be construed as endorsement by the Agency for Healthcare Research … ECHO trains
rural healthcare professionals to provide the same level of care to rural patients as they … mission of improving healthcare quality and safety for rural and underserved
populations.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
September 01, 2015 - The Problem
Health care-associated infections are one of the most common complications of hospital … .2 Catheter-associated urinary tract infections are among the most common types of
health care-associated … increased length of stay of 2-4 days, patient
discomfort, and excess health care costs, and contribute … Only health care workers, family members, or patients themselves who know the correct
technique of aseptic … Multistate
point-prevalence survey of health care–associated
infections.
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www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
September 01, 2015 - The Problem
Health care-associated infections are one of the most common complications of hospital … .2 Catheter-associated urinary tract infections are among the most common types of
health care-associated … increased length of stay of 2-4 days, patient
discomfort, and excess health care costs, and contribute … Only health care workers, family members, or patients themselves who know the correct
technique of aseptic … Multistate
point-prevalence survey of health care–associated
infections.
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hcup-us.ahrq.gov/reports/statbriefs/sb71.pdf
April 01, 2009 - Csection
deliveries, including elevated risk of mortality. 7 In light of the
importance of childbirthrelated … hospitalizations in the healthcare
system, it is important to better quantify and understand the impact … About HCUP
HCUP is a family of powerful health care databases, software tools, and products for advancing …
Virginia Health Information
Washington State Department of Health
West Virginia Health Care Authority …
obtaining more information about access, cost, use, financing, and quality of health care in the United