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psnet.ahrq.gov/issue/adverse-events-and-near-misses-relating-information-management-hospital
December 29, 2014 - Comparison of accuracy of physical examination findings in initial progress notes between paper charts
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psnet.ahrq.gov/issue/evaluation-medication-errors-pediatric-surgical-service-experience
March 02, 2011 - December 2, 2014
Identifying medication errors in surgical prescription charts.
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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
-
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
-
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015339-aranaydo-final-report-2007.pdf
January 01, 2007 - tailored to the ambulatory care that THP provide could transform a handwritten or typed
paper medical chart … Extraction of Diabetic Audit data elements for annual reporting to the IHS
began with manual chart audits … of randomly selected medical charts. … legacy IHS RPMS system
allows some GPRA data to be abstracted electronically, it still required a paper chart … For the first time the providers have access to a legible up-to-date chart complete with
medications
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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…
-
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
-
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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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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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/bloomfield-h-et-al-2005
January 01, 2005 - the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart … the relative effectiveness of three different prompts (progress notes, patient letters, or computer chart … Chart reminders consisted of a short phrase that appeared on the cover page of the patient's computerized … This reminder was visible to the clinician when s/he opened a specific patient chart at the time of the … three groups, each receiving a different type of prompt: progress notes, patient letters, and computer chart
-
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
-
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.
-
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
-
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.
-
psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - unit clerk usually put the death certificate folder on the counter next to the
deceased patient's chart … This time, the chart next to the death certificate was Mr. B's chart. The intern
grabbed Mr. … B's chart, mistakenly believing that this was Mr. … A's chart, and looked at the contact
information on the front sheet. … It was at that point that
he discovered that he had the wrong chart. He called Mrs.
-
psnet.ahrq.gov/node/45976/psn-pdf
December 21, 2017 - errors in the
era of electronically prepopulated medication
reconciliation forms: a retrospective chart … errors in the era of
electronically prepopulated medication reconciliation forms: a retrospective chart … This retrospective
chart review study compared a research pharmacist–generated gold standard medication