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psnet.ahrq.gov/issue/preeminent-hospitals-penalized-over-rates-patients-injuries
January 17, 2018 - the legacy of the penalties, the data's ability to be effectively applied across various types of institutions
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psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time
July 19, 2018 - highlights the need to address communication breakdowns and normalization of deviance in health care institutions
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - List two key barriers to incorporation and reconciliation of information transmitted between institutions … are the main barriers to achieving interoperability across information technology systems and across institutions … to facilitate the transmission of patient information instantly and seamlessly between health care institutions … The HITECH Act requires current health IT systems and health care institutions to be able to rapidly … barriers to rapid and seamless transmission of patient care data include financial incentives that prevent institutions
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - Many institutions (such as the Dana-Farber Cancer Institute ) have prioritized engaging patient representatives … error prevention therefore risks simply shifting the responsibility for safety from providers and institutions
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psnet.ahrq.gov/issue/duke-surgery-patient-safety-open-source-application-anonymous-reporting-adverse-and-near-miss
February 15, 2011 - their hospital's surgical department that can be modified and adapted for use in other departments or institutions
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psnet.ahrq.gov/issue/perspective-road-map-academic-departments-promote-scholarship-quality-improvement-and-patient
July 02, 2014 - This commentary describes how academic medical institutions can promote quality improvement and patient
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psnet.ahrq.gov/issue/crossing-quality-chasm-new-health-system-21st-century
July 08, 2016 - It is a call to action for providers and institutions as well as a strategic guide for clinicians, administrators
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psnet.ahrq.gov/node/44434/psn-pdf
June 21, 2016 - Hospitals with high management scores were also more likely to be teaching institutions.
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psnet.ahrq.gov/issue/development-patient-safety-web-based-education-curriculum-physicians-nurses-and-patients
March 29, 2023 - July 14, 2010
Barriers to implementation of patient safety systems in healthcare institutions
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psnet.ahrq.gov/issue/solving-puzzle-improving-safety-outcomes
September 07, 2022 - December 19, 2012
Barriers to implementation of patient safety systems in healthcare institutions
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - use
Describe potential errors associated with use of TSOACs
List best practices for individuals and institutions … to order TSOAC-specific tests when such tests are indicated
20
20
Institutional Responsibility
Institutions … appeared when the clinician tried to order an anticoagulant in a patient with an epidural catheter
Institutions
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - ,
further tightened in 2011, markedly increased the number of handoffs among trainees in training
institutions … tried diverse approaches tailored to the culture, workforce, and patient population of particular institutions … rates, important data emerged
supporting the premise that such penalties may unfairly penalize certain institutions
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - That was appropriate when the adverse events just happened and they cost institutions more money to take … to University Healthsystem Consortium (UHC) use these PSIs to rate the quality of care at different institutions … coding has been in place for more than a decade, found that patterns in POA coding differed across institutions … Variation in ICD-9-CM Coding and Limitations of Reporting
Variation is not only evident across institutions … Today, however, the variability of thoroughness of reporting and accuracy of coding across institutions
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - What this does for the people doing the analysis, and for the institutions where they work, is create … WM : I believe we see the world the same way you do in terms of individual institutions that have not … So we are defining the queries that providers or institutions want to make, we're defining the data that … That will allow local institutions to run their own reports without having to wait to get them back from … With rare events (such as wrong-site surgery), aggregation and review across many institutions can provide
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - With rare events (such as wrong-site surgery), aggregation and review across many institutions can provide … What this does for the people doing the analysis, and for the institutions where they work, is create … WM : I believe we see the world the same way you do in terms of individual institutions that have not … So we are defining the queries that providers or institutions want to make, we're defining the data that … That will allow local institutions to run their own reports without having to wait to get them back from
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psnet.ahrq.gov/issue/reducing-adverse-drug-events
August 09, 2017 - The book will be valuable to individuals and institutions attacking the problem of medication errors
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psnet.ahrq.gov/issue/national-voluntary-consensus-standards-patient-safety-measures-consensus-report
January 11, 2013 - safety problems (such as medication errors) were not reliable enough to be used for comparison across institutions
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psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
March 23, 2012 - When such an event occurs, many institutions mandate performance of a root cause analysis .
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psnet.ahrq.gov/issue/no-fault-compensation-medical-injuries-prospect-error-prevention
May 20, 2015 - postulate that such a system would encourage error reporting and could be linked to reforms that make institutions
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psnet.ahrq.gov/issue/apology-errors-whose-responsibility
September 27, 2016 - Lucian Leape calls for institutions to establish full disclosure, apology , and compensation policies