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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - consultation with the patient’s family, it was determined that emergency
surgery was not consistent with his goals
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - , 2019
Linking Joint Commission inpatient core measures and National Patient Safety Goals
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - One of the main goals is to understand the healthcare work processes that could be changed to eliminate
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - RW : Clearly there are times those goals are synergistic, where something that is safer will actually
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - hospital's performance improvement committee to implement improved shift change policies is a laudable goal … To my knowledge, few existing hospital policies fully accomplish this goal. … Joint Commission on Accreditation of Healthcare Organizations. 2007 National Patient Safety Goals. … All decisions require making trade-offs on competing goals. … Sacrifices to safety goals to meet economic and production goals are common occurrences that are not
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psnet.ahrq.gov/issue/five-hospitals-release-data-inspections
August 24, 2016 - January 27, 2015
Meeting the Joint Commission's 2013 National Patient Safety Goals. … June 3, 2009
2009 National Patient Safety Goals.
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psnet.ahrq.gov/patient-safety-101
March 26, 2025 - Patient Safety 101: The Fundamentals
What is Patient Safety?
The breadth of the field of patient safety is captured in various definitions. It has been defined as avoiding harm to patients from care that is intended to help them. 1 It involves the prevention and mitigation of harm caused by err…
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - RW: How do you balance that goal with the concern that we don't overload people with too many alarms
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - While decreases in harms are certainly our goal, a decrease in downstream
measures of harm can provide
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - Whether the goal was to
give them feedback or to make an assessment about whether they're good enough
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - The goal now is to figure out how we move that forward. How is it scalable?
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - My goal is always to be transparent and communicate medication errors to my staff.
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - RW: How do you balance that goal with the concern that we don't overload people with too many alarms
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - The first step in task decomposition is task analysis, which takes many forms based on the goal of the
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - The first step in task decomposition is task analysis, which takes many forms based on the goal of the
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - We will review this case using a human factors approach (1,2), the
overall goal of which is to identify … Designing Effective Interventions to Address Deficiencies of Teamwork and Communication The
goal of … The Five "C´s" of Effective Teamwork in Health Care*
Common goal
Every team member shares and understands … the short- and long-term goals of the team
and the organization. … Commitment Every team member is committed to attaining the goals.
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Better quality of health care should be the primary goal and should take precedence over other
stakeholder
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - guidelines described by the Joint Commission
See Notes for references.
2008 National Patient Safety Goals … The Joint Commission Accreditation Program: Ambulatory Health Care National Patient Safety Goals. … information fails to be conveyed or is forgotten
See Notes for references.
2008 National Patient Safety Goals … The Joint Commission Accreditation Program: Ambulatory Health Care National Patient Safety Goals. … include the following items (see next slide)
See Notes for reference.
2008 National Patient Safety Goals
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - )
16
Systems Approach to Improving Safety
• Appropriate training and supervision around ACP or goals-of-care … new code status could prevent an adverse event
20
Take-Home Points
• Code status discussions, “goals-of-care … to obtain a code status for
patients that includes their individual preferences, surrogates, and
goals … Vital Talk: Address Goals of Care. … Accessed Nov 2019 via the Web at https://www.vitaltalk.org/topics/reset-
goals-of-care/
13.
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - developed a toolkit of Patient Safety Essentials
designed to improve teamwork and communication with the goals