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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024755-hettinger-final-report-2019.pdf
January 01, 2019 - occur is a necessary and significant starting point, the next step is
to understand why these errors happen … analyze
recorded video of clinical EHR use in order to understand how EHR-related safety hazards happen … Wrong Side
Wrong sided surgeries are a never event in modern healthcare yet they continue to happen … of patient harm but nonetheless
could help better understand why issues of wrong sided procedures happen … error occurs is a
powerful tool for change that is amplified when the same error is demonstrated to happen
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digital.ahrq.gov/sites/default/files/docs/page/2006FreebairnSmith_051311comp.pdf
June 16, 2021 - “While I support the general concept of EMR, and would love to see
it really happen in the ED, piecing
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digital.ahrq.gov/ahrq-funded-projects/care-transitions-app-patients-multiple-chronic-conditions
January 01, 2023 - Lipika Samal and Patricia Dykes from Brigham and Women’s Hospital wanted to know what would happen if
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digital.ahrq.gov/sites/default/files/docs/resource/James_Veline_IQHIT_Q6_Compliance_and_Adherence_Patient_Handout.pdf
June 16, 2021 - It can happen to anyone. Try
making a schedule for yourself on a calendar.
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digital.ahrq.gov/program-overview/research-stories/displaying-patient-photos-medical-records-reduces-errors-improves
January 01, 2023 - “Orders placed on the wrong patient should be a ‘never event,’ as in it should never happen,” said Dr
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digital.ahrq.gov/program-overview/research-reports/2022-year-review/research-spotlight
January 01, 2022 - To make this happen, priorities may need to shift to fund more research that is conceptual or exploratory
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digital.ahrq.gov/2020-year-review/research-summary/anesthesiology-control-tower-air-traffic-control-operating-rooms
January 01, 2020 - the nearby airplanes and helping them to coordinate their activity, and prioritizing what needs to happen
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digital.ahrq.gov/sites/default/files/docs/medicaid/health-it-implementation.pdf
December 01, 2005 - .
– Many providers still worry about what will happen if the system goes
down or is hacked?
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/log
January 01, 2023 - Log
Also Known As
Work Log
Work Diary
Examples
EHR Implementation Issues Log ( PDF , 573KB)
Scanning Record Log ( PDF , 12KB)
Timed Office Visit Log ( PDF , 92KB)
Description
A log is a generic data collection form used for recording what has been done, when it was done, …
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digital.ahrq.gov/methods
January 01, 2023 - classified studies as a "predictive analysis" if they used modeling techniques to predict what might happen
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-virtual-multimedia-interactive-informed-consent-vic
January 01, 2023 - In the intervention arm, 96 percent of patients were able to correctly identify what would happen to
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixF_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - Poor connection to a wall 1
“Other Organizational Factors”
Unclear feedback to user on what would
happen
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digital.ahrq.gov/ahrq-funded-projects/theory-based-patient-portal-elearning-program-older-adults-chronic-illnesses
January 01, 2023 - A Theory-Based Patient Portal eLearning Program for Older Adults With Chronic Illnesses
Project Final Report ( PDF , 410.68 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necess…
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digital.ahrq.gov/2018-year-review/research-spotlights/leveraging-health-it-test-solutions-are-replicable-scalable-and
January 01, 2018 - “Placing orders on the wrong patient should never happen.
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digital.ahrq.gov/ahrq-funded-projects/providing-evidence-and-developing-toolkit-accelerate-adoption-patient
July 31, 2023 - “Orders placed on the wrong patient should be a ‘never event,’ as in it should never happen,” said Dr … “Placing orders on the wrong patient should never happen.
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digital.ahrq.gov/sites/default/files/docs/medication-without-harm-qas-07242024.pdf
July 24, 2024 - a
combination of those things, we came up with a 30-minute cutoff, although it may be that errors
happen
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/scatter-diagram
January 01, 2023 - Scatter Diagram
Also Known As
Scatter Plot
X-Y Graph
Description
A scatter diagram consists of pairs of numerical data containing one variable on each axis. The diagram is used to find a relationship between the data pairs. Points that create a line or curve indicate correlated variables…
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digital.ahrq.gov/sites/default/files/docs/survey/improving-sickle-cell-transitions-focus-group-moderator-guide-patients.pdf
June 16, 2021 - Improving Sickle Cell Transitions, Focus Group Moderator Guide: Patients
Improving Sickle Cell Transitions, Focus Group Moderator Guide: Patients
The Lewin Group, Inc., Falls Church Virginia
This is a focus group guide designed to be to be conducted with patients across a health care
system. The tool includes …
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digital.ahrq.gov/2020-year-review/research-summary/improving-delivery-health-services-health-systems-level
January 01, 2020 - While errors may happen at all stages of the medication process, different tools have been developed
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/kepner-tregoe-matrix
January 01, 2023 - Kepner-Tregoe Matrix
Also Known As
Is-Is Not Matrix
Kepner and Tregoe Method
Description
A Kepner-Tregoe matrix is used to find causes of a problem. It isolates the who, what, when, where, and how aspects of an event, keeping the focus on the elements that have an impact on the event and…