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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851462/psn-pdf
    July 19, 2023 - Broken Trust: Making Patient Safety More than Just a Promise. July 19, 2023 Manchester, UK: Parliamentary and Health Service Ombudsman; June 2023. ISBN: 9781528642446. https://psnet.ahrq.gov/issue/broken-trust-making-patient-safety-more-just-promise Lack of accountability for systemic contributions to failure degr…

  2. Patient portal as a tool for enhancing patient experience and improving quality of care in primary care practices. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/evaluating-effectiveness-health-information-technology-self-management-program/citation/patient
    January 01, 2023 - Patient portal as a tool for enhancing patient experience and improving quality of care in primary care practices. Citation Sorondo B, Allen A, Fathima S, et al. Patient portal as a tool for enhancing patient experience and improving quality of care in primary care practices. EGEMS (Wash DC) 2017 Jan…

  3. What Happened on Telemetry? | PSNet

    psnet.ahrq.gov/web-mm/what-happened-telemetry
    January 18, 2012 - WebM&M Cases Delay in Malignancy Diagnosis Reflects Systemic Failures

  4. Beeline to Spine | PSNet

    psnet.ahrq.gov/web-mm/beeline-spine
    March 01, 2014 - WebM&M Cases Delay in Malignancy Diagnosis Reflects Systemic Failures

  5. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)

    www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf
    January 01, 2004 - because we believed that it offers a conceptual approach to codification that could help elucidate failures … Looking across the three tables, several combinations of codes appear to offer different pictures of failures

  6. In Conversation with…Pat Croskerry, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
    June 01, 2010 - theme is getting your colleagues and yourself to be comfortable learning about and hearing about your failures … To be frank with people and let them know what's coming and the sorts of failures that they're going

  7. Building Capacity for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/building-capacity-patient-safety
    July 31, 2023 - Perspectives on Safety Annual Perspective Impact of System Failures … Perspectives on Safety Annual Perspective Impact of System Failures

  8. Final Progress report: Creating High Reliability Organizations (pdf file)

    www.ahrq.gov/sites/default/files/2024-03/small-report.pdf
    January 01, 2024 - , epidemiological evidence for patient safety improvement, organizational psychology of systems failures … These failures of communication and coordination had a negative impact on resource utilization (duplication

  9. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Pace.pdf
    January 01, 2004 - because we believed that it offers a conceptual approach to codification that could help elucidate failures … Looking across the three tables, several combinations of codes appear to offer different pictures of failures

  10. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
    January 25, 2008 - patient information; or causes due to recklessness, negligence, or external causes related to human failures … However, it requires an evaluation of the event to document the possibility of specific communication failures

  11. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
    June 04, 2008 - causation is related to the design of systems and to the culture of care, rather than to individual human failures … For damages and injuries resulting from structural failures, water migration (mold and mildew), and

  12. Final Progress Report: Minimizing Error, Maximizing Outcome (MEMO): The Physician Worklife Study II (pdf file)

    www.ahrq.gov/sites/default/files/2024-09/linzer-schwartz-report.pdf
    January 01, 2024 - There is an open discussion of clinical failures. 1.9 (0.8) * In response to “To what degree do the … involvement of physicians in most financial decisions” (1.8), “There is open discussion of clinical failures

  13. Development of Dashboards to Provide Feedback to Home Care Nurses - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/development-dashboards-provide-feedback-home-care-nurses/final-report
    January 01, 2023 - Development of Dashboards to Provide Feedback to Home Care Nurses - Final Report Citation Dowding D. Development of Dashboards to Provide Feedback to Home Care Nurses - Final Report. (Prepared by Visiting Nurse Service of New York under Grant No. R21 HS023855). Rockville, MD: Agency for Healthcare Res…

  14. Evolving health information technology and the timely availability of visit diagnoses from ambulatory visits: a natural experiment in an integrated delivery system. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/impact-health-information-technology-clinical-care/citation/evolving-health
    January 01, 2023 - Evolving health information technology and the timely availability of visit diagnoses from ambulatory visits: a natural experiment in an integrated delivery system. Citation Bardach NS, Huang J, Brand R, et al. Evolving health information technology and the timely availability of visit diagnoses from …

  15. RxSafe: Shared Medication Management and Decision Support for Rural Clinicians - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/rxsafe-shared-medication-management-and-decision-support-rural-clinicians/final-report
    January 01, 2023 - RxSafe: Shared Medication Management and Decision Support for Rural Clinicians - Final Report Citation Gorman PN. RxSafe: Shared Medication Management and Decision Support for Rural Clinicians - Final Report. Prepared by Oregon health & Sciences University under Grant No. R18 HS017102). Rockville, MD:…

  16. Using Precision Performance Measurement to Conduct Focused Quality Improvement - Final Report | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/using-precision-performance-measurement-conduct-focused-quality-improvement/final-report
    January 01, 2023 - Using Precision Performance Measurement to Conduct Focused Quality Improvement - Final Report Citation Baker DW. Using Precision Performance Measurement to Conduct Focused Quality Improvement - Final Report. (Prepared by Northwestern University under Grant No. R18 HS017163). Rockville, MD: Agency for …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40729/psn-pdf
    October 04, 2011 - Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. October 4, 2011 Cassidy CJ, Smith AF, Arnot-Smith J. Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning Syste…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44057/psn-pdf
    June 03, 2015 - Measuring nursing error: psychometrics of MISSCARE and practice and professional issues items. June 3, 2015 Castner J, Dean-Baar S. Measuring nursing error: psychometrics of MISSCARE and practice and professional issues items. J Nurs Manag. 2014;22(3):421-437. https://psnet.ahrq.gov/issue/measuring-nursing-error-p…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39274/psn-pdf
    November 23, 2016 - Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child. November 23, 2016 Wilson BL. Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child. J Spec Pediatr Nurs. 2010;15(1):84-7. doi:10.1111/j.17…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40857/psn-pdf
    October 19, 2011 - Novel analysis of clinically relevant diagnostic errors in point-of-care devices. October 19, 2011 Shermock KM, Streiff MB, Pinto BL, et al. Novel analysis of clinically relevant diagnostic errors in point-of- care devices. J Thromb Haemost. 2011;9(9):1769-1775. doi:10.1111/j.1538-7836.2011.04439.x. https://psnet.…
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