Results

Total Results: 3,868 records

Showing results for "individual".

101. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46963/psn-pdf
     April 18, 2018 - just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual … monitoring-anaesthetist-operating-theatre-professional-competence-and-patient-safety https://psnet.ahrq.gov/primer/individual-clinician-performance-issues

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40736/psn-pdf
     January 04, 2012 - preventing-wrong-site-procedure-and-patient-events-using-common-cause- analysis After several episodes of incorrect surgical procedures, a medical center conducted individual … root cause analyses and summarized the findings to identify common causes of each individual error.

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33670/psn-pdf
     July 01, 2008 - It's clear that individual investigators and institutions have discovered things that cause problems … One is that individual organizations don't seem to follow up on their root cause analyses very well. … Some solutions are at the level of making a policy or retraining an individual clinician. … Sometimes the solution is improving the performance of an individual. … And individual accountability, individual feelings of responsibility, and high moral fiber are crucial

104. Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients? | PSNet
     psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
     December 14, 2022 - and stroke to identify the types of transitions involved and whether reports included any evidence of individual … Few incident reports referenced individual or organizational learning (e.g., team discussions, root cause

105. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43735/psn-pdf
     January 20, 2015 - patient-safety-not-elective-debate-npsf-patient-safety-congress Past commentaries have explored the tension between balancing no blame and individual … accountability in patient safety, with one argument describing the need for health care to differentiate individual

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46691/psn-pdf
     December 06, 2017 - improved-policies-and-oversight-needed-reviewing-and-reporting-providers- quality-and-safety Tracking concerns related to individual … improved-policies-and-oversight-needed-reviewing-and-reporting-providers-quality-and-safety https://psnet.ahrq.gov/primer/individual-clinician-performance-issues

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46522/psn-pdf
     October 29, 2017 - This commentary argues that reporting outcomes at the individual, rather than organizational, level … time-transparent-standards-quality-reporting-health-care-organizations https://psnet.ahrq.gov/issue/what-role-individual-accountability-patient-safety-multi-site-ethnographic-study

108. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35596/psn-pdf
     February 17, 2011 - patient outcomes, an ongoing dialogue exists about how health care should address and hold accountable individual … Overall, the authors estimate for the population that nearly a quarter of individual physicians involved

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34715/psn-pdf
     February 18, 2011 - improvement, calls for understanding and revision of the production process rather than placing blame on the individual … He also calls for individual physicians to join in the movement, maintaining that these principles apply

110. Requirements for implementing a 'just culture' within healthcare organisations: an integrative review. | PSNet
     psnet.ahrq.gov/issue/requirements-implementing-just-culture-within-healthcare-organisations-integrative-review
     October 31, 2014 - A “ just culture ” balances organizational responsibility and individual accountability after an error … May 15, 2024 Individual characteristics that promote or prevent psychological safety

111. A systematic review of adult admissions to ICUs related to adverse drug events. | PSNet
     psnet.ahrq.gov/issue/systematic-review-adult-admissions-icus-related-adverse-drug-events
     March 16, 2016 - The review was limited by methodological problems with the definitions of adverse drug events used in individual … Medical errors reported by French general practitioners in training: results of a survey and individual

112. Organizational learning in the morbidity and mortality conference. | PSNet
     psnet.ahrq.gov/issue/organizational-learning-morbidity-and-mortality-conference
     June 09, 2015 - Morbidity and mortality (M&M) conferences have evolved from focusing on individual clinicians to system … acknowledged the importance of recognizing organizational trends and learning from errors at both the individual

113. Medical team training: applying crew resource management in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/medical-team-training-applying-crew-resource-management-veterans-health-administration
     April 30, 2014 - Individual hospitals selected among specific teamwork training programs developed by the VA's National … evaluation of the programs are described in detail, along with examples of projects carried out at individual

114. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33808/psn-pdf
     May 01, 2016 - waveform Alarm settings, limits, and delays Setting alarms based on clinical population instead of individual … These decisions should be based on the workflow and patient population for each individual unit. … Individual Patient As mentioned above, some hospitals set default parameters by overall patient population—such … enough data has been collected, it is recommended that alarms be configured specifically for each individual … electrode placement and preparation, default alarm limits and delays, and basing alarm settings on individual

115. Adverse Events in Hospitals: State Reporting Systems. | PSNet
     psnet.ahrq.gov/issue/adverse-events-hospitals-state-reporting-systems
     January 14, 2009 - that as of January 2008, 26 states had reporting systems in place, 23 states used the data to hold individual … Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual

116. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47317/psn-pdf
     August 15, 2018 - actions-needed-address-employee-misconduct-process-and-ensure- accountability Both organizational and individual … actions-needed-address-employee-misconduct-process-and-ensure-accountability https://psnet.ahrq.gov/primer/individual-clinician-performance-issues

117. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844052/psn-pdf
     July 01, 2012 - , healthcare-acquired infections, medication administration errors) versus other contexts, such as individual … Findings suggest that individual value placed on different safety-related interventions depends on context

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34690/psn-pdf
     February 10, 2011 - of the underlying, or "system," causes of the ADEs as distinct from attributing the ADEs solely to individual … nonpunitive systems approach as a more effective means of preventing error than approaches focused on the individual

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44203/psn-pdf
     August 04, 2015 - Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual … Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual

120. Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications. | PSNet
     psnet.ahrq.gov/issue/use-unsolicited-patient-observations-identify-surgeons-increased-risk-postoperative
     July 10, 2019 - Most patient safety problems can be ascribed to underlying systems failures, but issues with individual … This study extends upon prior research by demonstrating an association between patient concerns about individual