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Showing results for "addresses".

181. The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/evolution-root-cause-analysis
     February 26, 2025 - are an important part of any organization’s commitment to patient safety because they identify and address … This redesigned RCA methodology aimed to address the most persistent ineffectual issues with traditional … Another health system addresses emotional harms alongside physical ones, 6 and another integrates an … The introduction of RCA 2 addresses many challenges associated with traditional RCA processes, emphasizing … Although they appeared very thorough, sometimes the questions did not address the complexities of the

182. Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care | PSNet
     psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
     July 23, 2024 - systematic approach to understanding the problem and identifying solutions. 3   Identify ideas that address … Broad and targeted approaches may both be needed to address the scope of the challenge. … well with the existing workflow and that the clinical team agrees with the root cause the intervention addresses

183. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
     January 01, 2024 - However, when the concern is dismissed or ignored, the team member re-addresses it by stating they are … The constellation of symptoms is clear in retrospect, and it is surprising that nothing was done to address

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33624/psn-pdf
     December 01, 2005 - It still seemed like the only way to really address those issues was to treat it mostly as a systems … In any system, you need a regulatory approach that addresses the bad apples; for the other physicians … It does very little to help with prevention of medical injuries, and it does nothing to address the … Until you begin to address that by reducing the administrative costs associated with the system, compensating

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49562/psn-pdf
     May 01, 2008 - induced general anesthesia, and the resident remained in the room as the attending left the OR to address … He felt that his resident didn't speak up to adequately address the allergy concern, in part because … collectively discuss the case, but, given the requirements to ensure it occurs, best practices must also address … pole to speak up may be lost.(12) At selected institutions, a process is being put into place that addresses

186. Discharge Instructions in the PACU: Who Remembers? | PSNet
     psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
     August 05, 2009 - Rather than ACL repair, the surgeon performed microfracture to address damage to the intraarticular cartilage … The Commentary This case addresses the important and challenging topic of patient–provider communication … instructions and follow-up verbal interactions were inadequate and, therefore, failed to uncover or address

187. What Do We Know About Emergency Department Safety? | PSNet
     psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
     June 01, 2010 - memory, and decision making. 8  Lack of sleep is associated with increased medical error. 9 ,10   To address … There are several potential solutions to address environmental system issues. … Conclusions ED safety requires a multi-faceted approach that addresses provider knowledge, experience … poorly designed measures, as described by Wachter and colleagues. 20  Only an integrated approach that addresses

188. In Conversation with…Troyen A. Brennan, MD, JD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
     December 21, 2022 - It still seemed like the only way to really address those issues was to treat it mostly as a systems … In any system, you need a regulatory approach that addresses the bad apples; for the other physicians … It does very little to help with prevention of medical injuries, and it does nothing to address the inaccuracy … Until you begin to address that by reducing the administrative costs associated with the system, compensating

189. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet
     psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
     November 16, 2022 - elements (including people) can go right or wrong, HFE uses human-centered design processes and methods to address … This type of solution inherently addresses core design problems rather than relying on humans to adapt … the constant elements of the patient journey, SEIPS 2.0 emphasizes patient engagement and SEPIS 3.0 addresses … Systems engineering focuses on the development and oversight of a system to address a need. … To address some of those gaps, we created a trigger in the electronic health record.

190. What Does Simulation Add to Teamwork Training? | PSNet
     psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
     October 01, 2004 - , develop skills of teamwork, and enhance attitudes concerning teamwork.( 2 ) Didactic training may address … and attitudes The readings, lectures, and group exercises preceding simulations purposefully addresses

191. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836841/psn-pdf
     June 01, 2020 - Training for referring providers and the care coordination team that addresses strategies for working

192. Wrong Catheter in the Right Patient | PSNet
     psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
     May 16, 2022 - evidence, and may not be relevant to current practice. 1-3 The literature regarding VOs that does exist addresses … prevent wrong site, wrong procedure, and wrong person surgery was created by the Joint Commission to address … the operative site, and conducting a “time-out.” 9 The preoperative verification process seeks to address

193. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853773/psn-pdf
     September 27, 2023 - It addresses each of the four skills and how they interact and provides actionable ways for teams to

194. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/843151/psn-pdf
     February 01, 2023 - to increase documentation of SOGI data.20 This initiative provides a prospective model of care that addresses

195. Poor Prognosis | PSNet
     psnet.ahrq.gov/web-mm/poor-prognosis
     March 15, 2016 - Results of a survey of a random sample of 1,311 US internists suggest that the average internist addresses

196. The Forgotten Line | PSNet
     psnet.ahrq.gov/web-mm/forgotten-line
     March 11, 2011 - day), (iii) the attending with the team pulls the information shared into a plan that systematically addresses

197. Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
     January 01, 2023 - separated into several tasks in the emergency and hospital setting.13 • The biopsychosocial approach addresses

198. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866992/psn-pdf
     May 29, 2024 - psnet.ahrq.gov//#5 https://psnet.ahrq.gov//#6 Harm reduction offers a promising, evidence-based alternative to address … housing and food security, on substance use outcomes will also help tailor harm reduction strategies to address … Rahul Gupta, has openly supported harm reduction as part of a comprehensive strategy to address substance … This approach not only addresses the immediate needs of people who use substances but also contributes

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866205/psn-pdf
     July 10, 2024 - However, when the concern is dismissed or ignored, the team member re-addresses it by stating they are … The constellation of symptoms is clear in retrospect, and it is surprising that nothing was done to address

200. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854849/psn-pdf
     October 31, 2023 - User-centered EHR design that addresses the underlying drivers of using risky tools may improve the