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psnet.ahrq.gov/periodic-issue/periodic-issue-326
January 07, 2022 - Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage … and adverse events after initial assessment by ambulance clinicians: a cohort analysis. … facing complex healthcare systems into the design of diagnostic safety interventions. … healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers … work product”) developed when a healthcare provider works with a federally listed PSO under the Patient
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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - : dissatisfaction with test result management systems in primary care. … SAFER Self-Assessment. Test Results Reporting and Follow-Up. … Improving clinical practice using clinical decision
support systems: a systematic review of trials to … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - of research, and substantial innovations in both technology and delivery systems. … Structured communication tools such as situation-background-assessment-recommendation (SBAR) show promise … Improving general communication skills between health care providers and consumers is essential in medicine … errors" committed by competent people working in dysfunctional systems. … Healthcare Systems Ergonomics and Patient Safety. London, UK: Taylor & Francis Group; 2005:85.
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - event as a result of delayed assessment and treatment. … of patients and thousands of visits a day, we need to consolidate and use a single platform and manage … However, interestingly enough, the accelerant for our telehealth systems actually came from our outpatient … That being said, I think it is still incumbent on us as healthcare providers to prioritize patients’ … Department of Health and Human Services.
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - use of copying and pasting. … Association of Medical Directors of Information Systems consensus on inpatient electronic health record … Here's what I see a lot: 14-point review of systems with negatives as follows, and 80 items are listed … If I see a student or a resident blatantly copying the intellectual assessment of someone else, I call … Part of the reason I'm pulling forward that neuro exam day after day or that review of systems is because
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - absorbable sutures and the push for healthcare systems to increase value and decrease cost, this surgery … of between 13,500 and 86,000 physicians by 2036 and that health systems are responding by expanding … the role of nonphysician health care providers. 30 In addition, in the outpatient setting, medical assistants … Preoperative Patient Assessment and Education Evaluate and if needed treat the patient’s medical comorbidities … Staff Training and Education : Provide ongoing education and training for healthcare providers including
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - Case Objectives Describe the appropriate initial assessment of patients with chronic non-cancer pain … disorders, and who was marginally housed and lacked support systems. … Take-Home Points The initial assessment in managing patients with chronic non-cancer pain should … May 1, 2003
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See More About The Topic
Hospitals
Health … Care Providers
Risk Managers
Public Health
Opiates/Narcotics
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. … Department of Health and Human Services. … March 1, 2017
Patient safety, systems design and ergonomics. … June 1, 2012
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See More About The Topic
Hospitals
Health … Care Providers
Medicine
Opiates/Narcotics
Latent Errors
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - systems thinking and engineering principles—was a marvelous example
of translocational work. … institutions using a variety of real-world systems. … Evidence Report/Technology Assessment No. 43. … Human error and the problem of causality in analysis of accidents. … Role of computerized physician order entry systems in facilitating
medication errors.
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psnet.ahrq.gov/issue/safety-issues-and-concerns-neurological-patient-emergency-department
March 19, 2014 - May 17, 2006
Complexity and challenges of the clinical diagnosis and management of Long … health record systems: a systematic review. … October 22, 2014
How to use online clinician rating systems. … December 19, 2012
Effect of a systems intervention on the quality and safety of patient … March 8, 2023
Risk assessment of the acute stroke diagnostic process using failure modes
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psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
August 01, 2010 - of research, and substantial innovations in both technology and delivery systems. … Structured communication tools such as situation-background-assessment-recommendation (SBAR) show promise … Improving general communication skills between health care providers and consumers is essential in medicine … errors" committed by competent people working in dysfunctional systems. … Healthcare Systems Ergonomics and Patient Safety. London, UK: Taylor & Francis Group; 2005:85.
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psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
August 22, 2014 - The first one for me is consumer technology. … All of these devices and tests must be tracked over months to years, and they all need tracking systems … of poor health literacy, and building in surveillance systems for problems with adherence, medication … Development of a personalized bidirectional text messaging tool for HIV adherence assessment and intervention … Care Providers
Health Care Executives and Administrators
Safety Scientists
Primary Care
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - Regulatory bodies, health systems, and professional societies have all encouraged
providers to taper … Finally, all healthcare delivery systems should have systems in place to ensure that all patients receive … Although pain management specialists are not available in all health systems and communities, this PCP … Department of Health and Human Services. … Department of Health and Human Services.
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psnet.ahrq.gov/issue/understanding-and-improving-everyday-work-healthcare
May 13, 2020 - June 21, 0223
- June 21, 2023
Considering human factors and developing systems-thinking … of healthcare professionals and patients. … June 7, 2023
A systems analysis of work-related violence in hospitals: stakeholders, … Consumer Reporting System for Patient Safety Events. … , preventability, type of medication errors and risk factors.
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - As healthcare systems strive to improve outcomes and safety, it is important to focus on the needs of … providers. … Prescription Drug Monitoring Programs (PDMPS): What Healthcare Providers Need to Know. https://www.cdc.gov … in healthcare workers during the Covid-19 pandemic: a multinational cross-sectional study. … Care Providers
Anesthesiology
Emergency Medicine
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - systems-level issues that facilitate triggering of the superficial vein thrombosis illness script (which … adenoma" usually connotes benignity Preoperative clearance • "clearance" implies certainty in assessment … September 28, 2022
Using the Assessment of Reasoning Tool to facilitate feedback about … 2003
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See More About The Topic
Emergency Departments
Health … Care Providers
Emergency Medicine
Cardiology
Radiograph Interpretation Error
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psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - toll on healthcare workers in NHs. … providers for resident care, infection control materials, COVID-19-related expenses, and
increased … to form an
independent commission responsible for conducting a comprehensive assessment of how NHs … 2021, presenting a significant
challenge to healthcare systems throughout the nation. … Washington DC: The
National Consumer Voice for Quality Long-Term Care; ND.
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - A recent Cochrane Systematic review found that power imbalances between healthcare providers and patients … The leadership of organizations—hospitals, health systems, long-term care communities, ambulatory practices … workers should be aware of limitations that families might have based on the situation at hand. … Systems and equipment were not in place to handle the situation safely. … It came so suddenly and overwhelmed health systems so fast.
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - In one study of risk factors for QT prolongation, EHR alerts were shown to increase
assessment for QT … only 21% of EHR alerts led to physician action.9
Systems Change Needed/Quality Improvement Approach …
In response to the Case above, several systems issues can be addressed. … a repletion dose of potassium. 10 The same
systems intervention has been accomplished with improvement … A dietary consultation may have also been helpful to
provide an assessment of the patient’s nutritional
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - absorbable sutures and the push for healthcare
systems to increase value and decrease cost, this surgery … of between 13,500 and 86,000 physicians by 2036 and that
health systems are responding by expanding … the role of nonphysician health care providers.30 In addition,
in the outpatient setting, medical assistants … Preoperative Patient Assessment and Education
Evaluate and if needed treat the patient’s medical comorbidities … Staff Training and Education: Provide ongoing education and training for healthcare providers
including