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www.ahrq.gov/hai/pfp/haccost2017-ref.html
May 01, 2023 - About the Partnership: Community Based Care Transitions Program. … Available at: https://partnershipforpatients.cms.gov/about-the-partnership/community-based-care-transitions-program
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - reductions in trainee work hours, first in Europe and more recently the United
States, the number of care transitions … Assessing the quality of patient handoffs at
care transitions. Qual Saf Health Care. 2010;19:e44.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
September 01, 2009 - Handoffs & Transitions
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree … Handoffs & Transitions
12. Nonpunitive Response to Errors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemedication.pptx
May 01, 2017 - Admin.
14
Key Safety Elements: Teamwork Training
Communicate during transitions of care. … Communicate during transitions of care.14
Have high-reliability teams.
26
AHRQ Safety Program for Perinatal
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - From the Same Author(s)
Patient Safety Primers
Inpatient Transitions … 2024
Patient Safety Primers
Discharge Planning and Transitions
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www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
July 01, 2022 - Documentation of Mandated Discharge Summary Components in Transitions from Acute to Sub-Acute Care ( … High Hanging Fruit: Improving Transitions in Healthcare ( PDF , 100 KB )
Shawna J.
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - These differences create potential discrepancies in transitions of care (i.e., OR to ICU) and inconsistencies … November 1, 2023
Use of complete medication history to identify and correct transitions-of-care
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effectivehealthcare.ahrq.gov/get-involved/nominated-topics/what-is-the-effectiveness-of-interventions-designed-to-support-children-in-transition-from-pediatric-care-to-adult-care-with-special-health-care-needs-ineffective-transition-planning-can-have-significant-negative-consequence
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs018229-dalal-final-report-2012.pdf
January 01, 2012 - Key Words: tests pending at discharge; automated email notification; care transitions
The authors … In fact, as our
18
healthcare network transitions to a new, vendor-based EMR (Epic Systems,
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www.ahrq.gov/sites/default/files/wysiwyg/funding/training-grants/rachel-hogg-graham-application.pdf
May 19, 2021 - His research focuses on quality improvement, care transitions, teamwork and the role of
Page 67 … has also been
actively engaged in qualitative work to better understand the effectiveness of care transitions … are related to the constellation of community organizations
with which hospitals partner for care transitions … are related to the constellation of community organizations
with which hospitals partner for care transitions … other community agencies, and an
indicator of hospitals that report working with both in their care transitions
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - or discharge orders.( 14 ) Given the patient safety risk posed by medication discrepancies during transitions … Take-Home Points Failure to reconcile medications during transitions of care accounts for many preventable
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - 40% of these hospitalizations occurring within the first 3 months of nursing home admission.( 15 ) Transitions … Prior studies have shown that transitions in care are associated with an increased risk of adverse events
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psnet.ahrq.gov/node/43654/psn-pdf
April 02, 2015 - Nursing bedside clinical handover—an integrated review
of issues and tools.
April 2, 2015
Anderson J, Malone L, Shanahan K, et al. Nursing bedside clinical handover - an integrated review of
issues and tools. J Clin Nurs. 2015;24(5-6):662-671. doi:10.1111/jocn.12706.
https://psnet.ahrq.gov/issue/nursing-bedside-cl…
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psnet.ahrq.gov/node/44636/psn-pdf
November 04, 2015 - The most crucial half-hour at a hospital: the shift change.
November 4, 2015
Landro L.
https://psnet.ahrq.gov/issue/most-crucial-half-hour-hospital-shift-change
Information exchange can be challenging when nurses hand off care responsibilities at the end of their
shifts. This news article discusses bedside shift r…
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psnet.ahrq.gov/node/838085/psn-pdf
September 14, 2022 - Administering High-Strength Insulin from a Pen Device in
Hospital.
September 14, 2022
Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022.
https://psnet.ahrq.gov/issue/administering-high-strength-insulin-pen-device-hospital
Misuse of insulin pens contributes to never events associated with diabet…
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psnet.ahrq.gov/node/44359/psn-pdf
January 06, 2016 - What happens when healthcare innovations collide?
January 6, 2016
Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide?
BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441.
https://psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide
Innovat…
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psnet.ahrq.gov/node/43659/psn-pdf
November 05, 2014 - Intraoperative patient information handover between
anesthesia providers.
November 5, 2014
Choromanski D, Frederick J, McKelvey GM, et al. Intraoperative patient information handover between
anesthesia providers. J Biomed Res. 2014;28(5):383-387. doi:10.7555/JBR.28.20140001.
https://psnet.ahrq.gov/issue/intraopera…
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psnet.ahrq.gov/node/43566/psn-pdf
December 19, 2014 - Bedside shift reports: what does the evidence say?
December 19, 2014
Gregory S, Tan D, Tilrico M, et al. Bedside shift reports: what does the evidence say? J Nurs Adm.
2014;44(10):541-5. doi:10.1097/NNA.0000000000000115.
https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say
Bedside shift report…
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psnet.ahrq.gov/node/60163/psn-pdf
March 25, 2020 - Broken, fragmented health-care system failed daughter
who died by suicide.
March 25, 2020
Klowak M. CBC News. March 9, 2020.
https://psnet.ahrq.gov/issue/broken-fragmented-health-care-system-failed-daughter-who-died-suicide
System weaknesses are often at the root of never events. This news story discusses the suic…
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digital.ahrq.gov/ahrq-funded-projects/randomized-clinical-trial-smartphone-virtual-reality-pain-management-during/citation/features
January 01, 2024 - Features of virtual reality impact effectiveness of VR pain alleviation therapeutics in pediatric burn patients: A randomized clinical trial.
Citation
Jain S, Armstrong M, Luna J, Thakkar RK, Fabia R, Groner JI, Noffsinger D, Ni A, Nelson E, Xiang H. Features of virtual reality impact effectiveness of…