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psnet.ahrq.gov/node/37469/psn-pdf
January 16, 2008 - reduction of medication errors in
orthopedics and spinal surgery: outcomes using a
pharmacist-led approach … reduction of medication errors in orthopedics and spinal
surgery: outcomes using a pharmacist-led approach … towards-reduction-medication-errors-orthopedics-and-spinal-surgery-
outcomes-using-pharmacist
This study describes the successful efforts of a pharmacist-led approach … The approach included screening of orders and educational interventions.
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psnet.ahrq.gov/node/45560/psn-pdf
October 19, 2016 - Learning from excellence in healthcare: a new approach
to incident reporting. … Learning from excellence in healthcare: a new approach to incident reporting. … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
Learning … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/45321/psn-pdf
August 01, 2017 - Peer support for clinicians: a programmatic approach.
August 1, 2017
Shapiro J, Galowitz P. … Peer Support for Clinicians: A Programmatic Approach. … https://psnet.ahrq.gov/issue/peer-support-clinicians-programmatic-approach
Peer support programs can … https://psnet.ahrq.gov/issue/peer-support-clinicians-programmatic-approach
https://psnet.ahrq.gov/primer
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psnet.ahrq.gov/node/44521/psn-pdf
July 03, 2016 - Crib of horrors: one hospital's approach to promoting a
culture of safety. … Crib of Horrors: One Hospital's Approach to Promoting a Culture of
Safety. … https://psnet.ahrq.gov/issue/crib-horrors-one-hospitals-approach-promoting-culture-safety
Games illustrating … https://psnet.ahrq.gov/issue/crib-horrors-one-hospitals-approach-promoting-culture-safety
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/45592/psn-pdf
October 27, 2016 - Preventing Patient Falls: A Systematic Approach From
the Joint Commission Center for Transforming Healthcare … https://psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center-
transforming-healthcare … https://psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center-transforming-healthcare … https://psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center-transforming-healthcare
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psnet.ahrq.gov/node/44002/psn-pdf
March 25, 2015 - Preventing medication errors in transitions of care: a
patient case approach. … Preventing medication errors in transitions of care: A patient case
approach. … https://psnet.ahrq.gov/issue/preventing-medication-errors-transitions-care-patient-case-approach
Transitions … https://psnet.ahrq.gov/issue/preventing-medication-errors-transitions-care-patient-case-approach
https
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psnet.ahrq.gov/node/46086/psn-pdf
August 30, 2017 - Quality and Safety in Nursing: a Competency Approach to
Improving Outcomes, Second Edition. … https://psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second … https://psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition … https://psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition
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psnet.ahrq.gov/node/45228/psn-pdf
June 29, 2016 - An innovative approach to the surgical time out: a patient-
focused model. … An Innovative Approach to the Surgical Time Out: A Patient-
Focused Model. … https://psnet.ahrq.gov/issue/innovative-approach-surgical-time-out-patient-focused-model
The surgical … https://psnet.ahrq.gov/issue/innovative-approach-surgical-time-out-patient-focused-model
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/47057/psn-pdf
July 14, 2018 - A framework for operationalizing risk: a practical
approach to patient safety. … A framework for operationalizing risk: A practical approach to
patient safety. … https://psnet.ahrq.gov/issue/framework-operationalizing-risk-practical-approach-patient-safety
The patient … https://psnet.ahrq.gov/issue/framework-operationalizing-risk-practical-approach-patient-safety
https:
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psnet.ahrq.gov/node/45867/psn-pdf
April 12, 2017 - The Economics of Patient Safety: Strengthening a Value-
based Approach to Reducing Patient Harm at National … https://psnet.ahrq.gov/issue/economics-patient-safety-strengthening-value-based-approach-reducing-
patient-harm-national … https://psnet.ahrq.gov/issue/economics-patient-safety-strengthening-value-based-approach-reducing-patient-harm-national … https://psnet.ahrq.gov/issue/economics-patient-safety-strengthening-value-based-approach-reducing-patient-harm-national
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psnet.ahrq.gov/node/45533/psn-pdf
November 02, 2016 - Multimethod study of a large-scale programme to improve
patient safety using a harm-free care approach … Multimethod study of a large-scale programme to improve patient
safety using a harm-free care approach … psnet.ahrq.gov/issue/multimethod-study-large-scale-programme-improve-patient-safety-using-harm-
free-care-approach … psnet.ahrq.gov/issue/multimethod-study-large-scale-programme-improve-patient-safety-using-harm-free-care-approach … psnet.ahrq.gov/issue/multimethod-study-large-scale-programme-improve-patient-safety-using-harm-free-care-approach
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019. … https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the … The systems approach, by contrast, takes the view that most errors reflect predictable
human failings … Analyzing Errors Using the Systems Approach
The systems approach provides a framework for analysis of … FMEA makes sense as a general approach and has been used in other high-risk industries.
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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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digital.ahrq.gov/principal-investigator/dorr-david
January 01, 2024 - Dorr, David
Study protocol: Collaboration Oriented Approach to Controlling … Study protocol: Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) in adults … Project Name
Collaboration-Oriented Approach to Controlling High Blood Pressure (COACH) … Project Name
Collaboration-Oriented Approach to Controlling High Blood Pressure (COACH) … Clinical Decision Support
Description
This research developed the Collaboration Oriented Approach
-
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/867652/psn-pdf
February 26, 2025 - /perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach … //psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
https://psnet.ahrq.gov/primer/systems-approach … One new component of RCA2 is its structured approach to prioritizing harm events for investigation. … The RCA2 toolkit offers a flexible approach to root cause analysis, allowing healthcare organizations … This proactive
approach helps organizations identify potential risks before they result in actual harm
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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
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psnet.ahrq.gov/node/840170/psn-pdf
November 16, 2022 - errors in community pharmacies:
an application of the Systematic Human Error Reduction
and Prediction Approach … This qualitative study used an innovative approach to examine prospective medication dispensing errors … using a two-step approach. … medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
https://psnet.ahrq.gov/issue/beyond-corrective-action-hierarchy-systems-approach-organizational-change
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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