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Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. | PSNet

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August 30, 2023 - at national VA medical centers. … crowding: the canary in the health care system. … infections in 2020: a summary of data reported to the National Healthcare Safety Network. … same for health care, advocates say. … November 25, 2009 Patient Safety in Ambulance Services: A Scoping Review.

Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. | PSNet

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December 08, 2010 - These broad guidelines are aimed at coordinating diverse efforts from different stakeholder groups to … November 14, 2007 Physicians, information technology, and health care systems: a journey … June 10, 2015 A national survey assessing the number of records allowed open in electronic … May 18, 2022 Enabling a learning healthcare system with automated computer protocols … Health Care Executives and Administrators Information Professionals Policy Makers Medicine

The Unfinished Patient Safety Agenda | PSNet

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August 01, 2005 - Efforts to transform care at the bedside, including improved nurse staffing and working conditions, must … care services for the homeless. … It is a continuing puzzle that health care does not respond to economic and research indicators the same … June 25, 2014 Health Care Quality and Disparities: Lessons from the First National Reports … Health Care System.

What's changed 1 year after RaDonda Vaught's conviction? | PSNet

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October 13, 2021 - This news article examines how health care organizations renewed efforts to establish and nurture a … April 7, 2021 A hard look at hard stops and workarounds in the acute care setting. … Louis Health Care System in Missouri. … VA Salt Lake City Healthcare System in Utah. … March 22, 2023 Building a Culture of Safety in Health Care.

In Conversation With… Karl Bilimoria, MD, MS | PSNet

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December 01, 2017 - I didn't do very well, but they've devised an automated way to look at the mechanics of my swing and … His root cause analysis (though the term was not used in health care at that time) is an example of … Rather, it would lead to a hard look at the program's culture and structure.( 4 ) Within a strong safety … Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. … December 15, 2021 Letter to Health Care Providers: Safe Use of Surgical Staplers and

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge. | PSNet

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November 02, 2022 - of medical error on patients and families: state-wide cross-sectional survey. … A national prospective cohort study. … to 20 hospitals in England during implementation of the 7-day services national health policy. … February 16, 2022 Impact of providing patients access to electronic health records on … November 18, 2020 A high-reliability organization framework for health care: a multiyear

Sway: Unravelling Unconscious Bias | PSNet

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January 13, 2021 - March 28, 2018 Shifting the Mindset: A Closer Look at Hospital Complaints. … Health Care. … April 6, 2016 Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis … System: Current State and a Call to Action. … March 8, 2023 Access to Clinical Information at the Bedside.

Doing well by doing good: evaluating the influence of patient safety performance on hospital financial outcomes. | PSNet

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November 15, 2023 - health care. … September 21, 2016 Journey to no preventable risk: The Baylor Health Care System patient … October 1, 2014 Stigma and healthcare access among transgender and gender-diverse people … February 27, 2019 Active-shooter response at a health care facility. … February 14, 2018 Suffering in silence: medical error and its impact on health care providers

Medication administration discrepancies persist despite electronic ordering. | PSNet

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September 21, 2011 - pediatric health care–associated infections. … April 18, 2018 Creating a high-reliability health care system: improving performance … receiving home health care. … January 9, 2008 View More Related Resources A hard look at hard … and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship. | PSNet

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January 18, 2023 - the potential of this approach as a way to engage patients in safety efforts. … threats: a national survey of interns and residents. … Examining the frequency, types and senders of pages in academic medical services. … May 20, 2020 Health care provider factors associated with patient-reported adverse events … mistakes: experience at 3 U.S. healthcare centers.

In Conversation with...Sorrel King | PSNet

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March 01, 2007 - , or do something for kids in the health care setting. … You've got to look at the patient. … In some ways, you look at the steps that Hopkins has taken and it shows a lot of good people getting … have three roles in improving patient safety: helping to ensure their own safety, working with health … A second role for patients and family members is in working to improve safety and quality in health care

Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet

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November 01, 2006 - In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. … RW: How would you try to apply this thinking in a health care organization? … DN: The same philosophy has to be used to get computers in health care, or you're apt to make the problems … September 12, 2007 Improving the Reliability of Health Care. … and innovative approach to healthcare system safety.

Caution, Interrupted | PSNet

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October 01, 2016 - Similar efforts have begun in some areas of health care ( 14 ), but have yet to be implemented in a comprehensive … is new to health care, called "technical work studies … health care providers. … The messy details: insights from technical work studies in health care. … Louis Health Care System in Missouri.

Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records. | PSNet

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February 17, 2021 - March 3, 2021 Quality improvement as a primary approach to change in healthcare: a precarious … threats: a national survey of interns and residents. … June 1, 2022 Personal formularies of primary care physicians across 4 health care systems … March 22, 2023 Association between opioid tapering and subsequent health care use, medication … August 3, 2022 Outsourcing health-care services to the private sector and treatable mortality

World Patient Safety, Science & Technology Summit. | PSNet

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January 19, 2022 - Emergency at the VA Southern Nevada Health Care System in Las Vegas. … Louis Health Care System in Missouri. … System: Current State and a Call to Action. … April 2, 2014 Transforming Health Care: A Compendium of Reports From the National Patient … January 26, 2022 A hard look at hard stops and workarounds in the acute care setting.

A systematic review of the effect of telepharmacy services in the community pharmacy setting on care quality and patient safety. | PSNet

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September 15, 2021 - The use of telehealth to deliver health care services continues to expand. … transferred from hospital to home health care-a systematic review. … in Hospitals and Other Health Care Organizations. … August 10, 2022 Patient safety monitoring in acute care in a decentralized national health … care system: conceptual framework and initial set of actionable indicators.

In Conversation With… David Blumenthal, MD, MPP | PSNet

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July 01, 2012 - Innovation Officer, Partners HealthCare System and the Samuel O. … HealthCare System and Harvard Medical School. … In the present, it's better and almost everything we want to do to improve our health care system depends … For all I know, we will have such capable natural language processing that people will never look at … Statement of Commitment to Patient Safety and a Learning Healthcare System.

Diagnostic Delay in the Emergency Department | PSNet

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January 01, 2016 - Describe recommendations and approaches for individual physicians and health care organizations to address … [Available at] 7. Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care. … Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine … Editorial: Helping health care organizations to define diagnostic errors as missed opportunities in diagnosis … Oper Res Health Care. 2013;2:66-74. [Available at] 30. Upadhyay DK, Sittig DF, Singh H.

Teamwork in Healthcare. | PSNet

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May 16, 2018 - June 22, 2011 Improving the Health Care Work Environment. … November 5, 2014 Toward a High Performance Health System: Public-Private Efforts to Make … Health Care Safer and More Effective. … January 10, 2018 Health Care Equity January 31, 2024 Safety in EMS … December 12, 2007 Language Barriers in Health Care.

Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients with COVID-19. | PSNet

psnet.ahrq.gov/issue/racial-and-ethnic-discrepancy-pulse-oximetry-and-delayed-identification-treatment-eligibility

November 18, 2020 - April 12, 2023 A checklist to address implicit bias in healthcare settings during the … pragmatic insights from US health care organizations. … in a national patient safety collaborative. … with language proficiency in the US. … Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID

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