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Showing results for "patient safety".

441. The Mobile Mock Operating Room: Bringing Team Training to the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Paige_6.pdf
     January 24, 2008 - Methods: The MMOR, created and used to support the System for Teamwork Effectiveness and Patient Safety … Sample outline for a patient safety plan. 4. Undre S, Sevdalis N, Healy AN, et al. … Medical teamwork and patient safety: The evidence-based relation. Literature review. … TeamSTEPPS™: Strategies and tools to enhance performance and patient safety. … Using simulation-based training to improve patient safety: What does it take?

442. Pillars of a Smart, Safe Operating Room (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
     April 07, 2008 - It improves patient safety by moving the learning phase away from patients.2, 3 Typically, simulations … safety.5 Many patient safety issues arise not out of poor manual and procedural skills, but rather … Using information technology to improve patient safety has been a hallmark of recent patient safety … Such communication is necessary to ensure OR efficiency and patient safety. … Monitoring patient safety. Crit Care Clin 2007; 23: 659-673. 32.

443. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
     January 01, 2006 - The Quality and Patient Safety perspective is placed at the top indicating its priority importance in … safety data from internal safety reporting systems, patient satisfaction survey data, and work culture … to the PICU staff in order to evaluate teamwork and patient safety.6 A wide variety of staff and … Once these baseline measurements were obtained, the health system’s Chief Patient Safety Officer met … Areas of focus include patient safety, patient flow, and patient satisfaction.

444. Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gururaja_7.pdf
     January 24, 2008 - TeamSTEPPS™: Strategies and tools to enhance performance and patient safety. … Sample outline for a patient safety plan. Available at: www.ahrq.gov/qual/teamstepps. … Medical teamwork and patient safety: The evidence-based relation. Literature review. … Advances in patient safety: New directions and alternative approaches. … Evaluation of the System for Teamwork and Patient Safety (STEPS). Grant number 1 U18 HS016680.

445. Effect of Recent Refresher Training on in Situ Simulated Pediatric Tracheal Intubation Psychomotor Skill Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nishisaki_44.pdf
     April 19, 2008 - Medical simulation has been recognized as an effective tool to improve patient safety. … The role of simulation in patient safety. In: Dunn WF, eds. … Does simulation improve patient safety? … Self-efficacy, competence, operational performance, and patient safety. … Improving patient safety through simulation research.

446. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - Joint Comisssion perspectives on patient safety. Using FMEA to assess risk and reduce error. … Advances in patient safety: From research to implementation. … Incidence of adverse events and negligence in hospitalized patients. … Organizing patient safety research to identify risks and hazards. … Sensemaking of patient safety risks and hazards.

447. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Kind_31.pdf
     March 31, 2008 - Despite the critical importance of discharge summaries in care transitions and patient safety, no studies … discharge condition information is a concern and may affect patient safety. … One cancer patient, eight stroke patients, and four hip fracture patients were excluded. 2 Discharge … discharge condition information is a concern and may influence patient safety. … Patient safety concerns arising from test results that return after hospital discharge.

448. VHA’s National Falls Collaborative and Prevention Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stalhandske2_70.pdf
     March 01, 2006 - This article presents three successful patient safety fall prevention projects completed within the … Author Affiliations VHA National Center for Patient Safety, Ann Arbor, MI. … Stalhandske, MPP, MHSA, VHA National Center for Patient Safety, 24 Frank Lloyd Wright Drive, Lobby M … VA Patient Safety Event Registry: First Nineteen Months of Reported Cases Summary and Analysis. … Department of Veterans Affairs, Veterans Health Administration National Center for Patient Safety.

449. In Situ Simulation: Challenges and Results (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
     May 05, 2008 - When simulations typically occur in empty patient rooms, these rooms might be occupied by actual patients … However, patient safety research is performance research and studies the clinical care system. … patient safety investigation. … that might be related to patient safety issues. … Designing patient safety into the microsystem.

450. Efficiency Gains with Computerized Provider Order Entry (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
     March 18, 2008 - It also supports the effort to improve quality of patient care and patient safety. … In order to improve both quality of care and patient safety, health care systems are implementing CPOE … Efficiencies of the system support better patient safety and quality of care. … Eisenberg patient safety awards. … The Leapfrog Group for Patient Safety: rewarding higher standards, J Comm J Qual Saf 2003; 29: 634-

451. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - This study highlighted an opportunity to embed the culture of patient safety to promote safe medication … and fostering a culture of patient safety. eMAR and barcoding represent the use of technology to prevent … Barcode medication and patient armband scan rates were evaluated for compliance with patient safety … This study highlighted an opportunity to embed the culture of patient safety. … Limiting override access could decrease medication errors and improve patient safety throughout the

452. Clinical Pharmacists in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
     February 21, 2008 - A qualitative study to derive an EPh role optimized for patient safety is also described. … safety solution.31, 35, 36 A recent analysis of patient safety practices by the Agency for Healthcare … in patient safety). The framework approach involves five major steps. … Promoting patient safety and preventing medical error in emergency departments. … A critical analysis of patient safety practices. AHRQ Pub. No. 01-E058.

453. Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
     November 30, 2010 - • Determine whether a structured MTM program focused on patient safety increases patient satisfaction … The primary outcome of ADEs reflects the study focus on patient safety. … • Construct an MTM intervention that promotes patient safety. … Study outcomes (Table 3) are all linked to patient safety. … The optimal design of MTM programs for improving patient safety remains unclear.

454. Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/index.html
     August 01, 2023 - Advances in Patient Safety and Medical Liability Advancing Patient Safety . … AHRQ-Funded Patient Safety Research Featured in Health Affairs . … AHRQ Papers on Diagnostic Safety Topics Becoming a High Reliability Organization: Operational Advice … Grantee Final Reports: Patient Safety .  … Longitudinal Evaluation of the Patient Safety and Medical Liability Reform Demonstration Program Making

455. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
     January 01, 2007 - Were there any consequences for the patient? … The value of educating physicians, house staff, and medical students about patient safety cannot be … Safety, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA. … Disruptive behavior in obstetrics: A hidden threat to patient safety. … Physician perception of hospital safety and barriers to incident reporting.

456. Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
     January 01, 2021 - • RN hours/patient day. • Licensed hours/patient day. Ratios • Number of patients/RN. … • Patient (bed) turnover as a percent of total patient days. … Patient outcome variables Patient falls and injury falls • Patient falls/1,000 patient days. … Unit-level staffing effectiveness report for total hours per patient day and falls for 1,000 patient … First do no harm: Executive briefing on medication safety.

457. Challenges to Real-Time Decision Support in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
     January 01, 2007 - Future output, testing, and development of the TR & R Project are described Safety and Errors in Emergency … safety and outcomes rely on strategies to ameliorate or eliminate the impact of human limitations.5 … and significantly reduce resuscitation time.9 In the complex environment of receiving areas for patients … Gaba DM Structural and organizational issues in patient safety: A comparison of health care to other … JAMIA 2007; 14: 141-145. 14 Abstract Introduction Safety and Errors in Emergency Medical Care

458. Role of the External Coach in Advancing Research Translation in Hospital-Based Performance Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Donaldson_87.pdf
     April 23, 2008 - care and reducing patient falls … Consistently implemented 19 64 A guide to reevaluation of fall risk 55 57 Inclusive of sitters/safety … variables 52 96 Medications patient was on at time of fall 27 75 Equipment in use 46 82 Patient … assessment (FRA) on admission (%) 94 100 Intervals of fall risk assessment defined as: Q shift on all patients … 40 64 Q shift on at-risk patients 36 4 Other 24 32 Fall risk assessment tool Internally developed

459. Harnessing the Potential of Health Care Collaboratives: Lessons from the Keystone ICU Project (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Goeschel_24.pdf
     January 01, 2008 - communication, teamwork, and ultimately, patient safety. … morning rounds to clearly outline a plan of care and identify potential safety hazards for each patient … Our goal is to learn with confidence what works to improve clinical outcomes and patient safety to benefit … We learned lessons from the KICU teams that have infused all of our subsequent patient safety efforts … Goeschel both receive honoraria for speaking about improving quality and patient safety.

460. Improving Referral Communication Using a Referral Tool Within an Electronic Medical Record (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gandhi_22.pdf
     February 01, 2007 - MD, MS Abstract Objectives: Poor outpatient referral communication is an important quality and safety … Finally, patients of intervention PCPs were more likely than patients of control PCPs to report that … Patient survey. … We started with patient age, patient sex, insurance status, intervention status, and specialty. … NS = not significant Patient Surveys As summarized in Table 6, intervention patients were significantly