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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - surgeon: a qualitative study of expert opinions on assuring performance and supporting safe career transitions … More
Related Resources
WebM&M Cases
Lost in Transitions
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - Transitions of care are high-risk points for error, allowing insertion of “pseudo-information,” and enabling … Profiles in Patient Safety: Emergency care transitions.
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digital.ahrq.gov/program-overview/research-reports/2022-year-review/research-themes-and-findings
January 01, 2022 - as well as decrease healthcare utilization
Completed
A Patient-Facing App to Improve Care Transitions … identify gaps, inconsistencies, and inefficiencies in discharge planning to inform improvements in transitions
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - post-operatively. 5 , 12,13 Systems Optimization A health system approach to safely manage medication transitions … Ions
April 28, 2021
WebM&M Cases
Lost in Transitions
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs024556-vest-final-report-2019.pdf
January 01, 2019 - While
strong use cases of HIE exist in the ambulatory care setting (e.g. care coordination across
transitions … using “pull” HIE after getting information via “push” HIE to obtain additional
information, support transitions
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - An Obstructed View
Citation Text:
Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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www.ahrq.gov/sites/default/files/2024-07/cox-carayon-report.pdf
January 01, 2024 - Asking the family for questions was associated with more positive views of the safety of handoffs and
transitions … domains—
overall perceptions of safety, openness of staff and parent communication, and handoffs and transitions … (0.8)
Family communication openness, mean (sd) 4.5 (0.6) 4.5 (0.6) 4.5 (0.6) 4.6 (0.6)
Handoffs and transitions … In addition, parents’ perceptions of the safety of
handoffs and transitions significantly increased … Element Overall Safety Staff Communication
Openness
Family Communication
Openness
Handoffs and
Transitions
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digital.ahrq.gov/sites/default/files/docs/page/2017-ahrq-hit-annual-report.pdf
January 01, 2017 - For example, in the Treating Comorbid Depression During Care Transitions with Relational
Agents project … improve
communication, coordination, and collaboration related to healthcare decision making
and care transitions … Interactive Patient-Centered Discharge Toolkit to Promote Self-
Management During Transitions PA-14-001 … Schnipper, Jeffrey
Lawrence
Electronic Medication Adherence Reporting and Feedback During
Care Transitions … Reporting of Data
on Interprofessional Intensive Care Unit Rounds PA-11-198
Gurses, Ayse Pinar Care Transitions
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psnet.ahrq.gov/node/74748/psn-pdf
February 09, 2022 - The abrupt expansion of ambulatory telemedicine:
implications for patient safety.
February 9, 2022
Khoong EC, Sharma AE, Gupta K, et al. The abrupt expansion of ambulatory telemedicine: implications for
patient safety. J Gen Intern Med. 2022;37(5):1270-1274. doi:10.1007/s11606-021-07329-9.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/851356/psn-pdf
July 12, 2023 - Leveraging the science of teamwork to sustain handoff
improvements in cardiovascular surgery.
July 12, 2023
Keebler JR, Lynch I, Ngo F, et al. Leveraging the science of teamwork to sustain handoff improvements in
cardiovascular surgery. Jt Comm J Qual Patient Saf. 2023;49(8):373-383. doi:10.1016/j.jcjq.2023.05.006.…
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psnet.ahrq.gov/node/866075/psn-pdf
June 05, 2024 - Oncology patients' willingness to report their medication
safety concerns from home: a qualitative study.
June 5, 2024
Bunni D, Walters G, Hwang M, et al. Oncology patients’ willingness to report their medication safety
concerns from home: a qualitative study. Support Care Cancer. 2024;32(6):352. doi:10.1007/s00520…
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psnet.ahrq.gov/node/849605/psn-pdf
May 31, 2023 - Identification of patient safety threats in a post-intensive
care clinic.
May 31, 2023
Karlic KJ, Valley TS, Cagino LM, et al. Identification of patient safety threats in a post-intensive care clinic.
Am J Med Qual. 2023;38(3):117-121. doi:10.1097/jmq.0000000000000118.
https://psnet.ahrq.gov/issue/identification-p…
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psnet.ahrq.gov/node/34993/psn-pdf
June 22, 2009 - Five system barriers to achieving ultrasafe health care.
June 22, 2009
Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern
Med. 2005;142(9):756-64.
https://psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
This commentary builds on the…
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psnet.ahrq.gov/node/73595/psn-pdf
August 11, 2021 - Safety committees need to proactively address the risk of
accidental cerebral injection of intravenous (IV) drugs.
August 11, 2021
ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5.
https://psnet.ahrq.gov/issue/safety-committees-need-proactively-address-risk-accidental-cerebral-injection-
…
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psnet.ahrq.gov/node/866434/psn-pdf
August 07, 2024 - Measuring the overall development of patient safety in a
new hospital using trigger tools.
August 7, 2024
Adamovic I, Dahlem P, Brachmann J. Measuring the overall development of patient safety in a new
hospital using trigger tools. Int J Qual Health Care. 2024;36(3):mzae064. doi:10.1093/intqhc/mzae064.
https://psn…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/avoiding-common-pitfalls
January 01, 2013 - It is essential to take a more active and coordinated approach in dealing with referrals and care transitions
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_5.pdf
October 01, 2016 - ..........................................................................4
Care Coordination and Transitions … ”
– Mary Hopkins, Clinic Manager
Care Coordination and Transitions
Centralized elements of the WellMed … Description and Practice Panel Size
Model of Care
Workforce Configuration
Care Coordination and Transitions
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digital.ahrq.gov/organization/university-southern-mississippi
January 01, 2023 - University of Southern Mississippi
Creating Online Newborn Intensive Care Unit (NICU) Networks to Educate, Consult & Team - 2009
Principal Investigator
Rachal, Valerie
Project Name
Creating Online Newborn Intensive Care Unit (NICU) Networks to Educate, Consult & …
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psnet.ahrq.gov/node/836960/psn-pdf
April 20, 2022 - Effect of a multispecialty faculty handoff initiative on
safety culture and handoff quality.
April 20, 2022
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Effect of a multispecialty faculty handoff initiative on safety
culture and handoff quality. Pediatr Qual Saf. 2022;7(2):e539. doi:10.1097/pq9.0000000000000539.
…