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  1. psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    February 22, 2023 - This perspective includes the contribution of Dr. … Graber’s pioneering work on diagnostic error in 2005, which includes an identification of systemic problems … Clinical decision making is a complex process that includes a variety of factors. … Clinician-centered misdiagnosis is only a part of overall diagnostic safety; the NASEM definition also includes … guidance that scales to particular needs at the level of individual practitioner whose scope of work includes
  2. psnet.ahrq.gov/primer/disclosure-errors
    September 15, 2024 - This model includes full disclosure of adverse events, appropriate investigations, implementation of … Safe Practice 7: Disclosure includes standards for practitioners regarding the key components of disclosure
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36442/psn-pdf
    July 23, 2023 - new tools to measure its impact, supports increased emphasis on the role of patients in teams, and includes
  4. psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
    September 15, 2024 - Group I includes four (4) classes of surgical items that comprise a traditional “surgical count” performed … Group II includes dressings and drape towels, devices used during operations and procedures, and device … This group also includes multi-component implant systems. … In contrast to NQF, TJC opines that “after surgery” includes any time after completion of the wound skin
  5. psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
    May 16, 2022 - Relevant documentation includes the case history, physical examination, signed consent form, and pre-anesthesia … unlike verification for medication or imaging orders, the standard protocol for verifying procedures includes … established in the 1980s, IR has been transitioning to a more clinically focused care delivery model that includes … Global Consensus Statement Defining Interventional Radiology, the clinical scope and practice of IR includes
  6. psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
    January 17, 2012 - The system includes tools to prospectively identify process risks in an organization, analyze the ways
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45125/psn-pdf
    January 26, 2023 - This list includes medications recognized by clinicians and professional organizations as those suited
  8. psnet.ahrq.gov/issue/creating-high-reliability-health-care-system-improving-performance-core-processes-care-johns
    January 27, 2016 - The new governance structure includes oversight from a patient safety and quality board committee.
  9. psnet.ahrq.gov/primer/communication-between-clinicians
    September 15, 2024 - Current Context The Joint Commission includes "improving staff communication" as one of its National … The National Quality Forum also includes multiple approaches to enhancing communication as part of the
  10. psnet.ahrq.gov/print/pdf/node/73848
    July 01, 2022 - The site, maintained by the American College of Obstetricians and Gynecologists, includes... … It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis … It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis … The site, maintained by the American College of Obstetricians and Gynecologists, includes...
  11. psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
    February 28, 2024 - The website includes an updated Pocket Guide that provides a quick reference to key TeamSTEPPS concepts … and tools, and includes a diagram to show how everything fits together. … It includes a welcome guide specific to the patients and family caregiver audience. … The website also includes new simulation-based training modules , which can be used as tools to help … The core TeamSTEPPS materials on the website begin with an Introduction , which includes an overview
  12. psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
    February 28, 2024 - It includes a welcome guide specific to the patients and family caregiver audience. … The website also includes new simulation-based training modules , which can be used as tools to help … The core TeamSTEPPS materials on the website begin with an Introduction , which includes an overview … The website includes an updated Pocket Guide that provides a quick reference to key TeamSTEPPS concepts … and tools, and includes a diagram to show how everything fits together.
  13. psnet.ahrq.gov/primer/triggers-and-trigger-tools
    September 15, 2024 - The GTT includes 53 different triggers, some applicable to all patients and some inappropriate for certain … The GTT is practical for routine improvement efforts and not just research studies, and it includes detailed
  14. psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
    June 19, 2024 - creating treatment plans Incentives for improved provider performance A bottom-up approach to change that includes … occurs when a clot travels through the circulatory system to the lungs. 9 Venous thromboembolism (VTE) includes … team developed the VTE Collaborative, which is a multidisciplinary group of provider stakeholders that includes … creating treatment plans Incentives for improved provider performance A bottom-up approach to change that includes
  15. psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
    January 31, 2024 - included nearly 2500 women across 32 maternity hospitals. 11 The discussion about human milk safety includes … organized into six categories: Separation - minimize the separation of mother and baby Identification - includes … Dispensing practices - includes verifying dates/times when milk is dispensed. … acknowledgment of the specific error, how that error impacted the patient, and that the specific communication includes
  16. psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
    April 27, 2022 - prescribed to older adults upon discharge from the emergency department. 3  EQUIPPED implementation includes … Once PIMs are identified, effective implementation of deprescribing practices includes a shared decision-making … A national survey of older adults found that patients prefer deprescribing language that includes an … The least preferred language includes reference to the amount of effort required to take the medication
  17. psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - performed collectively and reliably, have been proven to improve patient outcomes.” 3 The RSI bundle includes … Problem Addressed Evidence demonstrates that a bundle of best practices, which includes … review of successes, challenges, and additional concerns. 2 Visual counter uses a white board that includes
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45167/psn-pdf
    May 25, 2016 - The toolkit includes videos, slides, gap analysis assessments and teaching materials.
  19. psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
    May 28, 2020 - This includes events reported directly by clinical sites and those from device manufacturers. … We’ve expanded the scope of what we view as “critical” for assuring the safety of products, and that includes … This includes our Breakthrough Devices Program, which covers devices intended to treat or diagnose life … This includes our work establishing medical device registries, our increasing work with industry, and
  20. psnet.ahrq.gov/issue/measure-dx-implementing-pathways-discover-and-learn-diagnostic-errors
    August 25, 2021 - September 30, 2020 The path to diagnostic excellence includes feedback to calibrate how

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