The PSNet Innovations Exchange highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or altered products, tools, services, processes, systems, policies, organizational structures, or business models implemented to improve or enhance quality of care and reduce harm.” The PSNet Innovations Exchange includes recently developed and tested innovations, updates to existing innovations that have been featured in AHRQ’s Health Care Innovations Exchange, as well as “emerging innovations,” which are original approaches to patient safety recently published in the peer-reviewed literature.
During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and... Read More
Started in response to rising maternal morbidity and mortality rates in the State of California, the California Maternal Quality Care Collaborative (CMQCC) has conducted several statewide maternal safety... Read More
Medical residents, alongside interns, nurses and attending physicians, are uniquely positioned to identify safety concerns because they are on the front lines of patient care.1 Residents can bring a fresh perspective that is informed by their cross... Read More
Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading to hospital readmission in the United States.1,2 To improve... Read More
Patient falls are a never event and a frequent focus of patient safety and quality improvement projects. This pediatric ICU implemented a colored alert system based on fall risk assessments for all admitted patients.
Community pharmacists encounter a wide range of challenges to medication safety. This study used a novel prospective method of predicting errors and developing remedial solutions.
Rapid response teams are intended to improve timely identification and management of clinically deteriorating patients, such as in-hospital cardiac arrest or stroke.
Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes... Read More
While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to... Read More
All Innovations (42)
- Quality Improvement Strategies(14)
- Communication Improvement(13)
- Technologic Approaches(13)
- Care Coordination(8)
- Education and Training(8)
- Error Reporting and Analysis(8)
- Policies and Operations(7)
- Specialization of Care(6)
- Human Factors Engineering(5)
- Logistical Approaches(5)
- Computerized Decision Support(4)
- Culture of Safety(4)
- Behavioral change(2)
- Research Directions(1)
- Medical Complications(9)
- Medication Safety(9)
- Discontinuities, Gaps, and Hand-Off Problems(7)
- Diagnostic Errors(3)
- Transitions of Care(3)
- Failure to rescue(2)
- Psychological and Social Complications(2)
- Surgical Complications(2)
- Alert fatigue(1)
- Device-Related Complications(1)
- Identification Errors(1)
- Nonsurgical Procedural Complications(1)
The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.
Children's Hospital Colorado requires clinicians in all inpatient and outpatient facilities to confirm any order entered into its computerized order entry system through a popup verification screen that includes a prominent photograph of the patient, along with other key information such as age and gender. The goal is to capture the clinician's attention and force him or her to verify that the order has been entered into the correct patient's chart.