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Showing results for "culture of safety".

9881. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49847/psn-pdf
      November 01, 2018 - The critical exchange of information and transfer of patient care responsibility that occurs in handoff … or transfer of inaccurate information due to inadequate handoff, pose a risk to patient safety and have … In 2006, The Joint Commission established a National Patient Safety Goal focused on handoffs.(1) Responding … of a resident handoff bundle. … Readers should not interpret any statement in this report as an official position of AHRQ or of the

9882. Assessing the Safety of Electronic Health Records: What Have We Learned? | PSNet
      psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
      September 01, 2017 - Assessing the Safety of Electronic Health Records: What Have We Learned? Dean F. … the range of safety problems and identify potential solutions. … Of course, EHR-related patient safety exists as a subset of an organization's overall safety programs … As such, another key facet of this work is for organizational leadership to create the blame-free culture … I'm very proud of this. We created a group of invested stakeholders in health IT safety.

9883. The Unfamiliar Catheter | PSNet
      psnet.ahrq.gov/web-mm/unfamiliar-catheter
      November 01, 2006 - An organizational approach to understanding patient safety and medical errors. … Patient Safety and Quality: An Evidenced-based Handbook for Nurses. … October 28, 2020 Patient safety: a consumer's perspective. … March 27, 2024 WebM&M Cases Culture Clash … Human factors analysis of latent safety threats in a pediatric critical care unit

9884. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - Depending on the culture and practices in the hospital, nursing staff should expect either a brief physician … Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions. … NHS National Patient Safety Agency. London, UK: National Health Service; 2011. … to Improve Diagnostic Safety in Older Adults. … Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

9885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850678/psn-pdf
      June 14, 2023 - Implementation of this innovation resulted in improved patient safety and quality for patients at high … higher level of care. … of the ICU is a potentially preventable patient safety issue associated with increased mortality and … Innovation Patient Safety Focus The innovation uses an early detection alert system to identify patients … Build and maintain a shared safety culture to minimize communication gaps.

9886. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
      psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
      May 31, 2023 - Innovation Patient Safety Focus This innovation is designed to reduce medical errors during the critical … Copy URL Related Resources Patient Safety … August 24, 2022 Patient Safety Innovations The University … training interventions on safety culture and patient safety in emergency departments: a systematic review … Modifications to medical emergency team activation criteria and implications for patient safety

9887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866995/psn-pdf
      October 30, 2024 - In today’s hospital culture, no patient should suffer as a result of reluctance of nurses, physicians … Patient safety over power hierarchy: a scoping review of healthcare professionals' speaking-up skills … AHRQ Patient Safety Network (PSNet). October 31, 2023. Accessed July 15, 2024. [Free full text] 6. … Patient safety issues from information overload in electronic medical records. … Advancing safety with closed-loop communication of test results. Quick Safety.

9888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33696/psn-pdf
      June 01, 2010 - He has gone on to become one of the world's foremost experts in safety in emergency medicine and in … thinking about patient safety different? … reflect your interest in safety and that you're particularly proud of? … It's been helped by the patient safety movement of course. … How did you get the culture to accept that? PC: It wasn't easy.

9889. In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives | PSNet
      psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
      July 10, 2024 - You touched a little on specific health plan measures of patient safety. … Health Plan Patient Safety Initiatives July 10, 2024 When we think of improving patient safety … of reimbursements to quality metrics related to patient safety outcomes. … Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting. … The role of insurers in maternity safety.

9890. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet
      psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
      January 13, 2010 - In today’s hospital culture, no patient should suffer as a result of reluctance of nurses, physicians … Garth Utter, MD MSc Consulting Editor, AHRQ’s Patient Safety Network (PSNet)  Professor Department of … Patient safety over power hierarchy: a scoping review of healthcare professionals' speaking-up skills … patient safety indicator. … Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

9891. Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet
      psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
      September 27, 2023 - For the patient’s own safety and the safety of ED staff, physical and chemical restraint were deemed … high-stress situations coupled with the bypassing of available layers of safety including pharmacist … time period (e.g., 48 hours) 2 In addition, healthcare organizations should promote a “stop-the-line” culture … Medication Safety Alert! … A comparison of the safety of olanzapine and haloperidol in combination with benzodiazepines in emergency

9892. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33858/psn-pdf
      May 01, 2018 - We didn't think about how technology would enable novel workflows that would improve quality, safety … What do you make of that? JH: Again, I am probably controversial in my belief here. … But I spend huge amounts of time with the CEOs of all of our EHR companies. … First, Beth Israel Deaconess has a 30-year culture of innovation: Doctors creating software for doctors … It's a culture. It is probably unlike any other culture in a United States health care.

9893. Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes | PSNet
      psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
      July 23, 2024 - Innovation Patient Safety Focus This innovation uses core patient safety communication and teamwork … Increased safety attitude: As measured by Safety Attitude Questionnaire, this same RCT found a significant … December 5, 2018 Predictors of likelihood of speaking up about safety concerns in labour … The Topic Obstetrics Obstetrical Nursing Communication between Providers Teamwork Culture … of Safety View More

9894. In Conversation With… John Halamka, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
      March 27, 2024 - We didn't think about how technology would enable novel workflows that would improve quality, safety, … What do you make of that? JH : Again, I am probably controversial in my belief here. … But I spend huge amounts of time with the CEOs of all of our EHR companies. … First, Beth Israel Deaconess has a 30-year culture of innovation: Doctors creating software for doctors … It's a culture. It is probably unlike any other culture in a United States health care.

9895. Do Not Disturb! | PSNet
      psnet.ahrq.gov/web-mm/do-not-disturb
      February 03, 2011 - This case identifies intertwined failures in four physician competencies that affect patient safety: … Recognizing the deleterious effects of fatigue leading to resident burnout and patient safety problems … The culture of "no blame," and system responsibility for potential or actual safety issues, can permit … Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 … October 26, 2011 Resident fatigue: is there a patient safety issue?

9896. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks | PSNet
      psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
      September 01, 2017 - panic or anxiety, and that error was twice as common in women as in men. 8 Approach to Improving Safety … & Patient Safety Target This case illustrates the risk of delayed diagnosis and missed diagnosis when … Research and Practice and the State of Massachusetts Betsy Lehman Center for Patient Safety, contributes … comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety … culture.

9897. Transfusion Thresholds in Gastrointestinal Bleeding | PSNet
      psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
      November 26, 2014 - Electronic health records provide templates for care and play a significant role in patient safety. … a hospital-wide patient safety improvement project on hospital-wide adverse event outcomes and patient … safety culture. … and simulations to improve patient safety: a multi-methods survey. … December 20, 2023 Understanding the peer, manager, and system influence on patient safety

9898. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet
      psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
      February 26, 2025 - plan by all team members can lead to a culture of better communication, greater engagement, and improved … Related Resources From the Same Author(s) Perspectives on Safety … September 2, 2020 Why is safety in intrapartum electronic fetal monitoring so hard? … February 7, 2024 Patient safety and the COVID-19 pandemic: a qualitative study of perspectives … May 15, 2024 View More Related Resources Patient Safety

9899. Language Barrier | PSNet
      psnet.ahrq.gov/web-mm/language-barrier
      February 28, 2024 - Language barriers were first identified as a patient safety issue in 2003 .( 9 ) Very little research … For optimal safety, especially when medication dosing is potentially confusing, LEP patients and/or … Such directly observed dosing has been shown to enhance safety and accuracy even when language barriers … As with patients who speak English, patient safety is greatest for LEP patients when provider-patient … The importance of language and culture in pediatric care: case studies from the Latino community.

9900. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73300/psn-pdf
      July 01, 2022 - can tailor components to align with their organizational needs, priorities, available resources, and culture … Williams was awarded one of 17 Partnerships in Implementing Patient Safety (PIPS) grants offered by … implementation kits and tools that facilitate the adoption of patient safety interventions. … Patient safety concerns arising from test results that return after hospital discharge. … AHRQ Patient Safety E-Newsletter. 2007 Aug 6;(34).