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Total Results: 7,150 records

Showing results for "involved".

241. The Evolution of Root Cause Analysis | PSNet
     psnet.ahrq.gov/perspective/evolution-root-cause-analysis
     February 26, 2025 - I became involved in RCA 2 as part of my role at Ochsner, a health system that was quickly expanding … In RCA 2 , we have small working teams without the staff involved in the adverse event. … Some organizations need help with this piece because they are accustomed to having the staff involved … Some of these events can be very traumatic, and we need to support the staff who have been involved. … As a learning organization, how are we sharing those results with the staff involved in the event, the

242. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
     May 01, 2010 - After the error was discovered, the nurse involved was fired by the hospital and her license was revoked … , expectations, or procedures that could get in the way Determine clinical knowledge of the person involved … have managed organization’s risk, but likely seen as unjust by all other major stakeholders: the nurse involved

243. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72550/psn-pdf
     January 01, 2022 - systems-approach-address-impact-second-victim-phenomenon https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

244. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841774/psn-pdf
     December 21, 2022 - psnet.ahrq.gov/issue/prosecution-radonda-vaught-ethical-and-legal-mistake The criminal conviction of a nurse involved

245. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73897/psn-pdf
     September 29, 2021 - https://psnet.ahrq.gov/issue/peer-support-toolkit Clinicians involved in adverse events that harm patients

246. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865346/psn-pdf
     March 27, 2024 - psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake Stories from clinicians involved

247. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865491/psn-pdf
     April 03, 2024 - https://psnet.ahrq.gov/issue/support-and-recovery-strategies-second-victims Clinicians involved in medical

248. Suicide Prevention in an Emergency Department Population: ED-SAFE | PSNet
     psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
     July 23, 2024 - Collaborative safety planning involved six-step safety plans created by clinicians and patients to help … innovation, organizations should consider the following: Buy-in from hospital leadership and all staff involved … The team must consist of members of the healthcare organization who are involved in the reduction of … innovation, organizations should consider the following: Buy-in from hospital leadership and all staff involved … It includes details like what to do first and includes the ways that every person involved in the innovation

249. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/859352/psn-pdf
     December 20, 2023 - They share how the system should adjust to better support those involved in mistakes and enable system

250. Managing alarm systems for quality and safety in the hospital setting. | PSNet
     psnet.ahrq.gov/issue/managing-alarm-systems-quality-and-safety-hospital-setting
     August 13, 2014 - September 21, 2016 Increased risk of burnout for physicians and nurses involved in a … April 10, 2019 Supporting involved health care professionals (second victims) following

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866355/psn-pdf
     July 24, 2024 - Most ADEs involved cardiovascular, central nervous system, or anti-infective medications.

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867046/psn-pdf
     October 30, 2024 - evaluating-incident-learning-systems-and-safety-culture-two-radiation-oncology-departments https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

253. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33594/psn-pdf
     November 18, 2021 - Its goals are to discuss the actions and thought processes involved in a particular clinical situation … the details of the event and to identify learning points for the staff and hospital system personnel involved … the type of debriefing to hold may include the seriousness of the event, the number of departments involved … convenience, other clinical obligations, any preexisting policies, and the personnel present and/or involved … to identify error and assign blame, but to understand why actions and decisions made sense to those involved

254. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/842432/psn-pdf
     January 11, 2023 - The piece discusses the medications involved, recommendations for improvement, and technologies to be

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836787/psn-pdf
     December 01, 2021 - psnet.ahrq.gov/issue/abandon-term-second-victim https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838028/psn-pdf
     September 15, 2022 - individuals for CRP conversations to ensure their effectiveness for patients, families, and professionals involved

257. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72598/psn-pdf
     January 01, 2021 - Errors involving medication prescribing or administration were most common; errors frequently involved

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47739/psn-pdf
     February 20, 2019 - The authors provide quality control questions to help those involved in developing AI systems detect

259. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/862996/psn-pdf
     February 21, 2024 - and 2020, researchers found that 59% of reports were submitted by consumers and events most commonly involved

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/858166/psn-pdf
     December 13, 2023 - Becoming a high reliability organization remains challenging due to the many contributing factors involved