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psnet.ahrq.gov/issue/was-close-call-endorsing-broad-definition-near-misses-health-care
August 31, 2016 - View More
Related Resources
Applied use of safety event occurrence control charts
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psnet.ahrq.gov/issue/role-cognition-generating-and-mitigating-clinical-errors
January 07, 2015 - December 16, 2020
Effect of number of open charts on intercepted wrong-patient medication
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psnet.ahrq.gov/node/47070/psn-pdf
June 25, 2018 - Time out—charting a path for improving performance
measurement.
June 25, 2018
MacLean CH, Kerr EA, Qaseem A. Time Out - Charting a Path for Improving Performance Measurement. N
Engl J Med. 2018;378(19):1757-1761. doi:10.1056/NEJMp1802595.
https://psnet.ahrq.gov/issue/time-out-charting-path-improving-performance-me…
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psnet.ahrq.gov/issue/reduction-incorrect-record-accessing-and-charting-patient-electronic-medical-records
September 29, 2017 - Study
Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.
Citation Text:
Rebello E, Kee S, Kowalski A, et al. Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative…
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digital.ahrq.gov/health-it-tools-and-resources/implementation-toolsets-e-prescribing/toolset-e-prescribing/tool-73-timeline-iha-ehr-transition
January 01, 2023 - Way before
Go-Live
Process Assessment
Assess Charting process
Begin chart … abstraction process using Internet Chart Abstraction Tool (ICAT)
Documentation of paper workflows
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psnet.ahrq.gov/node/38091/psn-pdf
February 18, 2011 - Questionable hospital chart documentation practices by
physicians. … Questionable hospital chart documentation practices by
physicians. … https://psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians
This study … https://psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians
https://psnet.ahrq.gov
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/PrescriptionRenewalRequest-PaperSystem.pdf
January 01, 2010 - A
P
ro
vi
de
r
P
at
ie
nt Call pharmacy
requesting
prescription renewal
Retrieve patient
chart … Give renewal
request and chart
to provider for
approval/
processing
Retrieve/transcribe
renewal … request
Approve or decline
renewal request or
change medication
Receive renewal
request result and
chart … from provider
File patient chart
Fax/phone
clinic for
renewal
Fax/phone
pharmacy
renewal
request
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhyCareAboutWorkflow.ppt
January 01, 2010 - patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart … Example (continued)
Before the EHR, a staff person provided each physician with the paper chart for … But, the EHR system you selected only allows one person to be logged into a patient chart at a time. … So, physicians can’t review charts before seeing the patient because a RN or MA is logged in while rooming … Delaying the physician entering the exam room for a few minutes so that there is time to review the chart
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs017020-singh-final-report-2010.pdf
January 01, 2010 - For each period (baseline and endpoint), research assistants reviewed an
independent sample of 100 charts … Charts identified in this first step as having triggers underwent secondary review (the ‘Review’
step … Patient Characteristics
Table 2 summarizes the demographic characteristics of the patients whose charts … over time.
8
Table 3: ADE’s , pADE’s, and severity in intervention and control sites
Total
charts … The outcome measure used for
ADE’s was based on chart review and therefore is limited.
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psnet.ahrq.gov/node/73298/psn-pdf
May 19, 2021 - The Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity.
May 19, 2021
National Academies of Sciences, Engineering, and Medicine. Washington DC: National
Academies Press; 2021. ISBN: 9780309685061.
https://psnet.ahrq.gov/issue/future-nursing-2020-2030-charting-path-achieve-he…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/cause-and-effect-diagram
January 01, 2023 - BRAINSTORM ALL POSSIBLE CAUSES and put them in the appropriate portion of the chart. … Go through the chart category by category. … It may be necessary to redraw the chart.
6. … Recommended Supplies/Materials
Flip chart
Advantages
Exposes limitations of existing
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psnet.ahrq.gov/node/42009/psn-pdf
December 19, 2018 - Charting the Course: Launching Patient-Centric
Healthcare.
December 19, 2018
Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128.
https://psnet.ahrq.gov/issue/charting-course-launching-patient-centric-healthcare
This book builds on concepts explored in Why Hospitals Shou…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs018236-ziemer-final-report-2012.pdf
January 01, 2012 - The chart was correct for 84% of
CORE medications. … Comparing the entire list of core medications by person showed only 38% of charts … In the chart, hypoglycemia questions were unanswered for 26% of subjects. … Standardized review for hypoglycemia shows 38% of CHARTs failed to address hypoglycemia
and had an overall … CHART HYPO question was not
answered 25% of time.
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digital.ahrq.gov/sites/default/files/docs/survey/tamc-provider-questionnaire.pdf
June 16, 2021 - Disease Registry
Tickler Sheet
Flow Chart
Posted Office Chart … Posted Office Chart
Other
Disease Registry
Tickler Sheet … Flow Chart
Posted Office Chart
Other
Disease Registry … Tickler Sheet
Flow Chart
Posted Office Chart
Other … Disease Registry
Tickler Sheet
Flow Chart
Posted Office Chart
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psnet.ahrq.gov/node/47551/psn-pdf
April 08, 2019 - Factors impacting physician use of information charted
by others.
April 8, 2019
Zozus MN, Penning M, Hammond WE. JAMIA Open. 2019;2:107-114.
https://psnet.ahrq.gov/issue/factors-impacting-physician-use-information-charted-others
The copy-and-paste phenomenon in clinical documentation can result in perpetuating inc…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/In-officePrescribing-PaperSystem.pdf
January 01, 2010 - ha
rm
ac
y
P
at
ie
nt
Patient sees
provider
Evaluate patient
Staff retrieves
patient’s chart … prescription and/or
renewal
Write out
prescription and/or
refill
Provider passes
patient chart … to
staff
Patient chart filed
Take prescription
and/or refill to
pharmacy
Fill prescription
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digital.ahrq.gov/sites/default/files/docs/page/2006Dye_051111comp.pdf
June 05, 2006 - • Shadow ICU nurses in the field to measure
events related to med administration
Trigger-based chart … 11 12 01 02 03 04 05
Pharmacy System EMAR CLIN DOC CPOE
Go-Live Go-Live
Trigger-based Chart … 11 12 01 02 03 04 05
Pharmacy System EMAR CLIN DOC CPOE
Go-Live Go-Live
Trigger-based Chart … Reviews
Prescribing Errors, Medication Errors, ADEs
14
Trigger Tool Chart Reviews
4 patient … = ADEs or med errors
– (prescribing errors in separate study)
• Track efficiency of triggers and chart
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psnet.ahrq.gov/node/47582/psn-pdf
December 12, 2018 - The HAPU incidence they found was about one-
twentieth of the HAPU incidence detected using chart review … In addition, while both chart review data and
administrative data showed a reduction in HAPU incidence … The authors suggest that using clinical data from chart review and taking ulcer severity into account
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hcup-us.ahrq.gov/reports/infographics/most-expensive-cond.jsp
December 01, 2013 - Total hospital costs in 2011 by condition and cost per payer (in billions):
(picture of a doughnut chart … Insurance: 18% ($3.7 billion)
Uninsured: 4% (less than $1.0 billion)
(picture of a doughnut chart … 39% ($5.7 billion)
Uninsured: Less than 1% (less than $1.0 billion)
(picture of a doughnut chart … Insurance: 25% ($3.2 billion)
Uninsured: 2% (less than $1.0 billion)
(picture of a doughnut chart … Insurance: 47% ($5.8 billion)
Uninsured: 2% (less than $1.0 billion)
(picture of a doughnut chart
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digital.ahrq.gov/sites/default/files/docs/page/percentage-of-verbal-orders-quick-reference-guide.pdf
March 01, 2009 - each accounting
for 38 percent of the orders.5
Source of Data for the Measure:
Preimplementation—chart … A simple chart or graph that displays the
decrease in verbal orders over time is an
effective way to … However, this may require manual chart
reviews, which can be expensive. … Any manual chart
review is resource intensive in terms of space, time,
and costs. … Consider whether these resources are
available before conducting any manual chart review.