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psnet.ahrq.gov/node/46751/psn-pdf
July 23, 2018 - A call for a systems-thinking approach to medication
adherence: stop blaming the patient. … A Call for a Systems-Thinking Approach to Medication Adherence: Stop
Blaming the Patient. … https://psnet.ahrq.gov/issue/call-systems-thinking-approach-medication-adherence-stop-blaming-patient … discusses factors that affect patient medication nonadherence and suggests that
a systems thinking approach … https://psnet.ahrq.gov/issue/call-systems-thinking-approach-medication-adherence-stop-blaming-patient
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psnet.ahrq.gov/node/40550/psn-pdf
June 22, 2011 - Applying a multidisciplinary approach to the selection,
evaluation, and acquisition of smart infusion … Applying a multidisciplinary approach to the selection, evaluation, and acquisition of smart
infusion … https://psnet.ahrq.gov/issue/applying-multidisciplinary-approach-selection-evaluation-and-acquisition … clinicians, patient safety experts, human factors engineers, and
biomedical engineers used a user-centered approach … https://psnet.ahrq.gov/issue/applying-multidisciplinary-approach-selection-evaluation-and-acquisition-smart-infusion-pumps
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psnet.ahrq.gov/node/43128/psn-pdf
August 25, 2015 - Locating errors through networked surveillance: a
multimethod approach to peer assessment, hazard
identification … Locating Errors Through Networked Surveillance: A
Multimethod Approach to Peer Assessment, Hazard Identification … https://psnet.ahrq.gov/issue/locating-errors-through-networked-surveillance-multimethod-approach-peer … -
assessment-hazard
This study describes a comprehensive approach to identifying safety hazards in … This type of in-depth, multidisciplinary approach shows
promise for determining and prioritizing safety
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psnet.ahrq.gov/node/44729/psn-pdf
January 07, 2016 - The morbidity and mortality meeting: time for a different
approach?
January 7, 2016
Fraser J. … The morbidity and mortality meeting: time for a different approach? … https://psnet.ahrq.gov/issue/morbidity-and-mortality-meeting-time-different-approach
Mortality and morbidity … of the traditional M&M conference model, this commentary advocates for a
proactive risk management approach … https://psnet.ahrq.gov/issue/morbidity-and-mortality-meeting-time-different-approach
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/47200/psn-pdf
August 20, 2018 - Creating a comprehensive, unit-based approach to
detecting and preventing harm in the neonatal intensive … https://psnet.ahrq.gov/issue/creating-comprehensive-unit-based-approach-detecting-and-preventing-harm … This commentary describes a broad
collaborative approach to improve the safety of neonatal intensive … The approach
involved the use of trigger tool technology, patient and family advisory councils, and … https://psnet.ahrq.gov/issue/creating-comprehensive-unit-based-approach-detecting-and-preventing-harm-neonatal-intensive
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psnet.ahrq.gov/node/41816/psn-pdf
September 26, 2016 - Designing for distractions: a human factors approach to
decreasing interruptions at a centralised medication … Designing for distractions: a human factors approach to decreasing
interruptions at a centralised medication … https://psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions- … interruptions while preserving a patient-centered
environment, this study used a human factors engineering approach … This approach resulted in
significantly fewer interruptions and improved staff satisfaction with medication
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psnet.ahrq.gov/node/33890/psn-pdf
January 04, 2017 - The faces of errors: a case-based approach to educating
providers, policy makers, and the public about … The faces of errors: a case-based approach to educating providers,
policymakers, and the public about … https://psnet.ahrq.gov/issue/faces-errors-case-based-approach-educating-providers-policy-makers-and- … public-about-patient
The development of a case-based approach to educate patients and providers about … https://psnet.ahrq.gov/issue/faces-errors-case-based-approach-educating-providers-policy-makers-and-public-about-patient
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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/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/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/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/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/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/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/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/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/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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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