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psnet.ahrq.gov/node/45322/psn-pdf
July 20, 2016 - their constant presence at patients' bedsides, and they
may have key insights into safety in their institutions
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psnet.ahrq.gov/node/41313/psn-pdf
January 18, 2017 - Lucian Leape calls for institutions to establish full disclosure, apology, and
compensation policies
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psnet.ahrq.gov/node/36294/psn-pdf
July 14, 2010 - This AHRQ–funded study
investigated whether institutions implementing care management achieved improvements
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psnet.ahrq.gov/node/40702/psn-pdf
October 16, 2012 - a diagnostic error, the authors discuss how collective
accountability would require clinicians and institutions
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effectivehealthcare.ahrq.gov/sites/default/files/module-ii-stakeholders-and-stakeholder-engagement.pdf
June 01, 2011 - This module is designed to
assist investigators and research institutions to effectively engage stakeholders … Health care policymakers at the Federal, state and local levels
§ Health care researchers and research institutions … level of involvement is that stakeholders have an ongoing relationship
with the EHC Program, research institutions … the engagement of external
stakeholders, those individuals and organizations outside the research institutions … vision of stakeholder involvement includes the development of ongoing relationships
between research institutions
-
effectivehealthcare-admin.ahrq.gov/sites/default/files/module-ii-stakeholders-and-stakeholder-engagement.pdf
June 01, 2011 - This module is designed to
assist investigators and research institutions to effectively engage stakeholders … Health care policymakers at the Federal, state and local levels
§ Health care researchers and research institutions … level of involvement is that stakeholders have an ongoing relationship
with the EHC Program, research institutions … the engagement of external
stakeholders, those individuals and organizations outside the research institutions … vision of stakeholder involvement includes the development of ongoing relationships
between research institutions
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - undergoing emergency laparotomy, there is increasing evidence of variability in patient outcomes between institutions … administrative data also suggests wide variation in outcomes for emergency general surgical admissions between institutions … hospitals with low mortality in elective operations may have high mortality in emergency surgeries.( 8 ) Institutions … Institutions that perform greater numbers of imaging investigations (e.g., ultrasound and computed tomography … There is significant variability in the quality of care and outcomes between institutions.
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - Therefore, even an optimal time out will not prevent all wrong site surgeries, forcing physicians and institutions … mode," so that the planned procedure is not started if a member of the team has concerns.( 2 ) In some institutions … that the time out take place immediately prior to the incision, a practice performed in many other institutions … require the presence and review of relevant radiologic images (if applicable).( 6 ) Furthermore, many institutions … without it, the ability of people lower on the totem pole to speak up may be lost.( 12 ) At selected institutions
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - results.( 7 )
In practice, a core group of tests ( Table ) appear on the panic value list of most institutions … Nearly all institutions will have alert values for glucose, sodium, potassium, hemoglobin, hematocrit … laboratory values and reduced delays in delivering appropriate treatment.( 13 )
For microbiology, most institutions … The fraction of institutions that include a positive test for C. difficile toxin on its list of panic … Laboratory critical values policies and procedures: a College of American Pathologists Q-Probes study in 623 institutions
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - In order to maximize timely adherence
to the bundle, institutions have created sepsis teams. … I suspect that many institutions that screen for severe sepsis and septic shock have
the bedside nurse … Institutions should work to develop systematic ways to screen patients in the ED and inpatient
units … In many institutions, pre-established protocols and guidelines provide specific recommendations. … Institutions should create robust patient safety and quality improvement programs to ensure
appropriate
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psnet.ahrq.gov/node/33670/psn-pdf
July 01, 2008 - about the effectiveness and efficiency of root cause analysis as a tool for helping them
improve their institutions … It's clear that individual investigators and
institutions have discovered things that cause problems … What then needs to happen is the institutions need to track what the
solutions are, and they need to … ought to do some
research on what kinds of solutions might be both effective and doable for individual institutions … and groups
of institutions.
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hcup-us.ahrq.gov/reports/methods/2012-02.pdf
January 01, 2012 - AHA as “non-Federal, short-term, general, and other specialty
hospitals, excluding hospital units of institutions … are: obstetrics-gynecology, ear-nose-throat, short-term rehabilitation, orthopedic,
and pediatric institutions … diabetes with short-term complications* (excluding obstetric admissions and transfers
from other institutions … (CHF) (excluding patients with cardiac procedures, obstetric
conditions, and transfers from other institutions … )
PQI 10 Admissions for dehydration (excluding obstetrical admissions and transfers from other institutions
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psnet.ahrq.gov/issue/creating-culture-safety
January 15, 2014 - Organizational culture and its implications for infection prevention and control in healthcare institutions
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psnet.ahrq.gov/node/37562/psn-pdf
June 14, 2011 - should focus at the level of the health care system to prevent the
inefficiencies of having individual institutions
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psnet.ahrq.gov/node/60539/psn-pdf
July 10, 2017 - Results suggest how institutions may wish to prioritize strategies to facility effective
care transitions
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psnet.ahrq.gov/node/44461/psn-pdf
June 21, 2016 - This study included many institutions, physicians, and procedure types,
suggesting that short-term sleep
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psnet.ahrq.gov/node/35229/psn-pdf
January 02, 2017 - patient-safety-leadership-walkroundstm-partners-healthcare-learning-
implementation
This study summarizes the experience of four institutions
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psnet.ahrq.gov/node/37471/psn-pdf
February 17, 2011 - training
of code teams with simulation methods, and particular attention to such training in teaching institutions
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digital.ahrq.gov/sites/default/files/docs/activity/implementing_and_improving_the_integration_of_decision_support_into_outpatient_clinical_workflow_2010_pdf__2.pdf
January 01, 2010 - Department of Veterans Affairs (VA), and
Partners Healthcare System—use different EMRs but are all institutions … titled, “Investigating
Integration of Computerized Decision Support into Workflow at Three Benchmark Institutions
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
January 01, 2005 - working collaboratively with a relatively small, well-trained representative
sample of health care institutions … FDA has approached these final three steps by exploring the barriers to
reporting within institutions … Step 6: Motivate users to report device
adverse events within their own institutions. … It has been imperative for FDA to fully understand
the barriers to reporting within the institutions … and to motivating the institutions to
send those reports to FDA.