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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Systems Change Needed/Quality Improvement Approach
It is not clear whether knowledge deficits or cognitive … Case
Sections
The Case
The Commentary
Systems Change Needed/Quality Improvement Approach
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - Approach to Improving Safety & Patient Safety Target
Swiss Cheese Model
Missed diagnoses are one of … system for closing the loop on important
non-urgent radiology findings: a multidisciplinary system-wide approach
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - We recommend a simple, four-step approach: (i) tell the patient what happened, using plain language; … An organization-wide approach to measuring and improving safety.
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - you think through what the goals are and how to balance measurement for transparency, as a regulatory approach … HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada.
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - In the past 2 years, we have seen a movement toward a hospital– and health system–wide focus on and approach
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psnet.ahrq.gov/node/837785/psn-pdf
August 05, 2022 - A human-centered approach that focuses on heterogenous user populations is
required to yield a satisfactory
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - A clinician-based approach.
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psnet.ahrq.gov/node/60167/psn-pdf
April 12, 2024 - The IDEAL discharge
planning strategy is one approach emphasizing patient and family engagement in discharge
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - action emphasizes that meaningful and lasting improvements in patient safety
require a total systems approach
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - Take-Home Points (2)
Clinical practices should leverage available technology to facilitate a team approach
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - hemodynamic stability has
been established, early mobilization can be achieved with an interdisciplinary approach
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Anyone who
has ever had to recount a pile of coins will recognize the potential problem with this approach
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Error Reduction in Health Care: A Systems Approach to Improving Patient Safety.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Approach to Improving Safety & Patient Safety Target Swiss Cheese Model Missed diagnoses are one of the … system for closing the loop on important non-urgent radiology findings: a multidisciplinary system-wide approach
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - a gait disturbance.( 15 ) Because many factors place patients at risk for falling, a multifactorial approach … A new approach to fall prevention in inpatient care: implementing remote audiovisual monitoring of at-risk
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - particularly prone to error. 11,12
System Errors Contributing to this Medication Error
A systems approach … Systems Change Needed/Quality Improvement Approach
Streamlined TPN re-ordering process
The
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - care setting is documented to be 23) The CDC also recommends streamlined counseling using an "opt-out" approach … This opt-out approach is similar to recommendations for routine screening in the prenatal setting.
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. … you think through what the goals are and how to balance measurement for transparency, as a regulatory approach
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psnet.ahrq.gov/Issues
June 23, 2021 - Healthcare professionals' encounters with ethnic minority patients: the critical incident approach … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid
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psnet.ahrq.gov/issues
June 23, 2021 - Healthcare professionals' encounters with ethnic minority patients: the critical incident approach … Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid