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psnet.ahrq.gov/node/46013/psn-pdf
January 01, 2018 - The dichotomy of the application of a systems approach
in UK healthcare the challenges and priorities … The dichotomy of the application of a systems approach in UK
healthcare the challenges and priorities … https://psnet.ahrq.gov/issue/dichotomy-application-systems-approach-uk-healthcare-challenges-and-
priorities-implementation … commentary uses case examples to illustrate how combining human factors
engineering and the systems approach … https://psnet.ahrq.gov/issue/dichotomy-application-systems-approach-uk-healthcare-challenges-and-priorities-implementation
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psnet.ahrq.gov/node/34650/psn-pdf
April 21, 2015 - human-error-models-and-management
The author discusses concepts of human error, contrasting the person approach … with a system approach in
understanding the differing philosophies of error management. … The person approach focuses on blaming
individuals, whereas the system approach concentrates on the … He explains the benefits of making the transition from a person approach to a system
approach in the
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psnet.ahrq.gov/node/837860/psn-pdf
August 17, 2022 - Alcoholism and American healthcare: the case for a
patient safety approach. … Alcoholism and American healthcare: the case for a patient safety approach. … https://psnet.ahrq.gov/issue/alcoholism-and-american-healthcare-case-patient-safety-approach
Implicit … https://psnet.ahrq.gov/issue/alcoholism-and-american-healthcare-case-patient-safety-approach
https://
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psnet.ahrq.gov/node/850351/psn-pdf
June 14, 2023 - A novel approach for assessing bias during team-based
clinical decision-making. … A novel approach for assessing bias during team-based clinical
decision-making. … https://psnet.ahrq.gov/issue/novel-approach-assessing-bias-during-team-based-clinical-decision-making … https://psnet.ahrq.gov/issue/novel-approach-assessing-bias-during-team-based-clinical-decision-making
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psnet.ahrq.gov/node/45696/psn-pdf
January 23, 2017 - Understanding patient safety performance and
educational needs using the 'Safety-II' approach for
complex … Understanding patient safety performance and educational needs
using the 'Safety-II' approach for complex … psnet.ahrq.gov/issue/understanding-patient-safety-performance-and-educational-needs-using-
safety-ii-approach … psnet.ahrq.gov/issue/understanding-patient-safety-performance-and-educational-needs-using-safety-ii-approach … psnet.ahrq.gov/issue/understanding-patient-safety-performance-and-educational-needs-using-safety-ii-approach
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psnet.ahrq.gov/node/43660/psn-pdf
November 12, 2014 - Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for … Developing a systematic approach to safer medication
use during pregnancy: summary of a Centers for … https://psnet.ahrq.gov/issue/developing-systematic-approach-safer-medication-use-during-pregnancy-
summary-centers-disease … disseminate evidence with the goal of providing guidance on these processes and developing a systematic
approach … https://psnet.ahrq.gov/issue/developing-systematic-approach-safer-medication-use-during-pregnancy-summary-centers-disease
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psnet.ahrq.gov/node/43580/psn-pdf
October 01, 2014 - Reducing medication errors in critical care: a multimodal
approach. … Reducing medication errors in critical care: a multimodal approach. … https://psnet.ahrq.gov/issue/reducing-medication-errors-critical-care-multimodal-approach
In light of … The authors recommend a
multimodal approach that combines system-level interventions, such as computerized … https://psnet.ahrq.gov/issue/reducing-medication-errors-critical-care-multimodal-approach
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/46849/psn-pdf
May 23, 2018 - 1,300 days and counting: a risk model approach to
preventing retained foreign objects (RFOs). … May 23, 2018
Duggan EG, Fernandez J, Saulan MM, et al. 1,300 Days and Counting: A Risk Model Approach … https://psnet.ahrq.gov/issue/1300-days-and-counting-risk-model-approach-preventing-retained-foreign- … https://psnet.ahrq.gov/issue/1300-days-and-counting-risk-model-approach-preventing-retained-foreign-objects-rfos … https://psnet.ahrq.gov/issue/1300-days-and-counting-risk-model-approach-preventing-retained-foreign-objects-rfos
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psnet.ahrq.gov/node/72814/psn-pdf
March 10, 2021 - Implementing a human factors approach to RCA(2) :
tools, processes and strategies. … Implementing a human factors approach to RCA(2) : tools,
processes and strategies. … https://psnet.ahrq.gov/issue/implementing-human-factors-approach-rca2-tools-processes-and-strategies … https://psnet.ahrq.gov/issue/implementing-human-factors-approach-rca2-tools-processes-and-strategies
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psnet.ahrq.gov/node/47399/psn-pdf
November 14, 2018 - Leveraging the continuum: a novel approach to meeting
quality improvement and patient safety competency … Leveraging the Continuum: A Novel Approach to Meeting Quality Improvement and
Patient Safety Competency … https://psnet.ahrq.gov/issue/leveraging-continuum-novel-approach-meeting-quality-improvement-and-
patient-safety-competency … The approach included activities such as event reporting, root cause analysis, and disclosure
simulation … https://psnet.ahrq.gov/issue/leveraging-continuum-novel-approach-meeting-quality-improvement-and-patient-safety-competency
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psnet.ahrq.gov/node/40782/psn-pdf
September 14, 2011 - Creating high reliability: a new approach for patient
safety.
September 14, 2011
McGinnis L. … Creating high reliability: a new approach for patient safety. AORN J. 2011;94(3):219-22. … https://psnet.ahrq.gov/issue/creating-high-reliability-new-approach-patient-safety
This commentary outlines … a comprehensive approach for creating and maintaining high reliability in health
care. … https://psnet.ahrq.gov/issue/creating-high-reliability-new-approach-patient-safety
https://psnet.ahrq.gov
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - an interdisciplinary person-centered care plan for fall
prevention would be appropriate.
17
APPROACH … TO FALL PREVENTION AND
IMPROVING RESIDENT SAFETY
18
Approach to Fall Prevention and Improving Patient … to Fall Prevention and Improving Patient Safety (5)
• In addition to using a multicomponent approach … to Fall Prevention and Improving Patient Safety (8)
• A person-centered approach to risk reduction … 29
Systems Change Needed/Quality Improvement Approach (1)
• A culture of safety is necessary to
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psnet.ahrq.gov/node/39127/psn-pdf
November 25, 2009 - An effectiveness analysis of healthcare systems using a
systems theoretic approach. … An effectiveness analysis of healthcare systems using a systems theoretic approach. … https://psnet.ahrq.gov/issue/effectiveness-analysis-healthcare-systems-using-systems-theoretic-approach … This study describes a theoretical systems approach to integrating quality measurement and reporting … https://psnet.ahrq.gov/issue/effectiveness-analysis-healthcare-systems-using-systems-theoretic-approach
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psnet.ahrq.gov/node/35918/psn-pdf
July 23, 2010 - Spinal surgery and patient safety: a systems approach.
July 23, 2010
Wong DA. … Spinal surgery and patient safety: a systems approach. J Am Acad Orthop Surg.
2006;14(4):226-32. … https://psnet.ahrq.gov/issue/spinal-surgery-and-patient-safety-systems-approach
The author reviews the … epidemiology of surgical adverse events from major epidemiologic studies and
discusses the need for a systems approach … https://psnet.ahrq.gov/issue/spinal-surgery-and-patient-safety-systems-approach
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psnet.ahrq.gov/node/35957/psn-pdf
August 02, 2010 - A practical approach to measure the quality of
handwritten medication orders: a tool for improvement … A Practical Approach to Measure the Quality of Handwritten
Medication Orders. … https://psnet.ahrq.gov/issue/practical-approach-measure-quality-handwritten-medication-orders-tool- … https://psnet.ahrq.gov/issue/practical-approach-measure-quality-handwritten-medication-orders-tool-improvement … https://psnet.ahrq.gov/issue/practical-approach-measure-quality-handwritten-medication-orders-tool-improvement
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psnet.ahrq.gov/node/40990/psn-pdf
December 07, 2011 - A novel approach to implementation of quality and safety
programmes in anaesthesiology. … A novel approach to implementation of quality and safety
programmes in anaesthesiology. … https://psnet.ahrq.gov/issue/novel-approach-implementation-quality-and-safety-programmes-
anaesthesiology … https://psnet.ahrq.gov/issue/novel-approach-implementation-quality-and-safety-programmes-anaesthesiology … https://psnet.ahrq.gov/issue/novel-approach-implementation-quality-and-safety-programmes-anaesthesiology
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psnet.ahrq.gov/node/38010/psn-pdf
August 27, 2008 - Detection of adverse events in surgical patients using the
Trigger Tool approach. … Detection of adverse events in surgical patients using the Trigger Tool approach. … https://psnet.ahrq.gov/issue/detection-adverse-events-surgical-patients-using-trigger-tool-approach … The tool was tested through
a collaborative approach between 11 hospitals, yielding a list of 23 clinical … https://psnet.ahrq.gov/issue/detection-adverse-events-surgical-patients-using-trigger-tool-approach
https
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psnet.ahrq.gov/node/37324/psn-pdf
February 16, 2011 - A complementary approach to promoting
professionalism: identifying, measuring, and addressing
unprofessional … A complementary approach to promoting professionalism:
identifying, measuring, and addressing unprofessional … https://psnet.ahrq.gov/issue/complementary-approach-promoting-professionalism-identifying-measuring- … The authors share their approach and model for addressing disruptive behavior,
and their related interventions … https://psnet.ahrq.gov/issue/complementary-approach-promoting-professionalism-identifying-measuring-and-addressing
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psnet.ahrq.gov/node/35395/psn-pdf
September 10, 2009 - Toward a theoretical approach to medical error reporting
system research and design. … Toward a theoretical approach to medical error reporting system
research and design. … https://psnet.ahrq.gov/issue/toward-theoretical-approach-medical-error-reporting-system-research-and- … https://psnet.ahrq.gov/issue/toward-theoretical-approach-medical-error-reporting-system-research-and-design … https://psnet.ahrq.gov/issue/toward-theoretical-approach-medical-error-reporting-system-research-and-design
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qualityindicators.ahrq.gov/Downloads/Modules/IQI/V2022/TechSpecs/IQI_21_Cesarean_Delivery_Rate_Uncomplicated.pdf
July 01, 2022 - 10D00Z2 Extraction of products of conception,
extraperitoneal, open approach
10D00Z1 Extraction … of products of conception,
low, open approach
Cesarean delivery procedure codes: (PRCSECP)
July 2022 … Rate, Uncomplicated
qualityindicators.ahrq.gov
10A00ZZ Abortion of products of conception, open
approach … 10A04ZZ Abortion of products of conception,
percutaneous endoscopic approach
10A03ZZ Abortion of … products of conception,
percutaneous approach
Hysterotomy procedure codes: (PRCSE2P)
July 2022 4