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digital.ahrq.gov/sites/default/files/docs/citation/r21hs021733-sheehan-final-report-2014.pdf
January 01, 2014 - Patient Self Monitoring to Transfer Physical Therapy Exercise from Clinic to Home - Final Report
Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
Project Title: Patient Self Monitoring to Transfer Physical Therapy Exercise from
Clinic t…
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psnet.ahrq.gov/node/49746/psn-pdf
October 01, 2015 - An Obstructed View
October 1, 2015
Carter J. An Obstructed View. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/obstructed-view
The Case
A 66-year-old man with a history of benign prostatic hyperplasia and obstructive sleep apnea presented to
the emergency department (ED) with subacute abdominal pain that …
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psnet.ahrq.gov/node/74766/psn-pdf
June 24, 2024 - Patient handoffs.
June 24, 2024
Arora V, Farnan J. UpToDate. June 24, 2024.
https://psnet.ahrq.gov/issue/patient-handoffs-0
The change of an inpatient’s location or handoffs between teams can fragment care due to communication,
information, and knowledge gaps. This review examines in-patient transition safety issu…
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digital.ahrq.gov/ahrq-funded-projects/implementing-personalized-cross-sector-transitional-care-management-promote/citation/role
January 01, 2023 - The role of telehealth and clinical informatics in data driven primary care redesign.
Citation
Brown JL, Hewner S. The role of telehealth and clinical informatics in data driven primary care redesign. J Inform Nurs. 2022;6(4):jin_21N4_A3. PMID: 35733915; PMCID: PMC9211055.
Link
https://pubmed.…
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/2016/2016_hospitalsops_report_pt1.pdf
January 01, 2016 - Handoffs & Transitions 48%
12. … Handoffs & Transitions
1. … Handoffs & Transitions
F3R 1. … Handoffs & Transitions 50% 48% 2% 32% -26% 5% -4%
12. … Handoffs & Transitions
F3R 1.
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and
Directo…
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digital.ahrq.gov/sites/default/files/docs/citation/r03hs024623-mendonca-final-report-2018.pdf
January 01, 2018 - Virtualized Homes: Tools for Better Discharge Planning - Final Report
AHRQ Final Report
Title of the project:
Virtualized Homes: Tools for Better Discharge Planning
Research Team:
Eneida A Mendonca, MD, PhD
Kevin…
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psnet.ahrq.gov/node/44357/psn-pdf
October 06, 2016 - Quality and Safety.
October 6, 2016
Albarran J, Scholes J, eds. Nurs Crit Care. 2015;20(4):167-220.
https://psnet.ahrq.gov/issue/quality-and-safety-0
Nurses have a key role in patient safety and advocacy in critical care settings. Articles in this special issue
explore the impact of interruptions on nursing care, …
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psnet.ahrq.gov/node/845653/psn-pdf
March 08, 2023 - Examples of Medical Device Misconnections.
March 8, 2023
Food and Drug Administration. February 23. 2023.
https://psnet.ahrq.gov/issue/examples-medical-device-misconnections
Mismatches of medical device connectors are known factors in therapeutic agent administration failures,
despite efforts to redesign equipment…
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psnet.ahrq.gov/node/43748/psn-pdf
December 03, 2014 - New enteral connectors: raising awareness.
December 3, 2014
Guenter P. New Enteral Connectors. Nutrition in Clinical Practice. 2014;29(5).
doi:10.1177/0884533614543330.
https://psnet.ahrq.gov/issue/new-enteral-connectors-raising-awareness
Redesigning tubing connectors according to new ISO standards has the potenti…
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digital.ahrq.gov/ahrq-funded-projects/implementing-personalized-cross-sector-transitional-care-management-promote/citation/ambulatory
January 01, 2024 - Ambulatory care coordination data gathering and use.
Citation
Geary CR, Hook M, Popejoy L, Smith E, Pasek L, Heermann Langford L, Hewner S. Ambulatory care coordination data gathering and use. Comput Inform Nurs. 2024 Jan 1;42(1):63-70. doi: 10.1097/CIN.0000000000001069. PMID: 37748014.
Link
h…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
July 01, 2023 - Hospital AIM
Team
Leads
SPPC‐II
Opportunities To Check‐Back
• During handoffs and care transitions … in these situations:
• Use a structured communication strategy like SBAR during handoffs and care
transitions … It can be used to
structure a general conversation or patient care transitions. … • Care transitions and handoffs
(e.g., during shift changes)
• Requesting a response during
emergent … Use SBAR to:
• Structure
communications, care
transitions, and
recommending
changes to the
-
www.ahrq.gov/sites/default/files/2024-01/landrigan-report.pdf
January 01, 2024 - Workshop Presentations
2015 I-PASS: Spreading an Evidence-based Program Across the Institution for
Safer Transitions … , San Diego, CA
2016 I-PASS: Spreading an Evidence-Based Program across the Institution for
Safer Transitions … Conference
2016 I-PASS: Improving Patient Safety by Standardizing Provider Communication and
Improving Transitions … Society for Hospital Medicine Annual Meeting
2018 Patient Safety Organization Webinar: Handoffs and Transitions … Using I-PASS in Psychiatry Residency Transitions of Care. SpringerLink.
-
www.ahrq.gov/sites/default/files/2024-02/schnipper2-report.pdf
January 01, 2024 - Scope: Unintentional medication discrepancies during care transitions are common - on average,
more … Key words: medication reconciliation, patient safety, hospitals, care transitions
3 | P a g e
Purpose … Scope:
Transitions of care (e.g., into and out of the hospital) are vulnerable times for patients due … Among the
hazards to patients after care transitions are medication discrepancies, defined as unexplained … Pharmacy-led medication reconciliation programmes at
hospital transitions: a systematic review and meta-analysis
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
April 01, 2023 - Toolkit To Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings
https://www.ahrq.gov … This toolkit helps staff actively engage patients and their care partners to prevent errors during
transitions … risk factors for ADEs, including health literacy, patient
characteristics, high alert medications and transitions … Shining a Light: Safer Health Care Through Transparency
Toolkit To Engage High-Risk Patients In Safe Transitions … Toolkit To Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings
10.
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www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-4.html
July 01, 2019 - The IHS also handles care transitions for patients leaving inpatient psychiatric care or detox facilities … by MAs, complex care management by care managers, and some behavioral health-related referrals and transitions … high-risk patients
Care managers work with high-risk patients, IHS manages detox and mental health transitions
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
December 01, 2013 - Transitioning Newborns from NICU to Home
Appendix B. Clinical Materials to Share With Primary Care Providers (continued)
Previous Page Next Page
Table of Contents
Transitioning Newborns from NICU to Home
A Resource Toolkit
Basic Components of the Health Coach Program
Family Information Packet …
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www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
December 01, 2013 - Transitioning Newborns from NICU to Home
Appendix B. Clinical Materials to Share With Primary Care Providers (continued)
Previous Page Next Page
Table of Contents
Transitioning Newborns from NICU to Home
A Resource Toolkit
Basic Components of the Health Coach Program
Family Information Packet …
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - cited category of root causes of sentinel events in hospitals.( 7 ) Communications during handoffs or transitions