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psnet.ahrq.gov/node/34639/psn-pdf
March 02, 2011 - The final
phase called for developing a screening tool to identify patients at admission who were at
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - In contrast, during the analytic phase, error rates are far lower. … Examples of errors encountered during the analytic phase typically resides with improper instrument … Sources of testing error occur during the post-analytic
phase include transcription errors, delayed … Medical
testing error occurs most frequently during the pre-analytic phase. … Risk management in the preanalytical phase of laboratory testing.
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - errors, with an error
rate of 78 per 100,000 visits.(5) Errors often occurred in the administration phase … In the case described, several factors contributed to the error at each phase of the medication-use process … The main contributors to the error during the prescribing
phase were duplicate orders and lack of a … In this case, the main contributors to the error during the pharmacist verification and dispensing phase … The administration phase is an important area to target for improved
drug administration safety.
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Preanalytic phase: clinician test selection, test ordering, specimen procurement, patient and specimen … Analytic phase: specimen processing, preparation, and assessment by the pathologist with immediate reporting … Postanalytic phase: receipt of the test results by the clinician followed by clinician interpretation … anatomic pathology, which have shown overall error rates of about 5% have estimated these rates by phase … : preanalytic phase (2.0%), analytic phase (0.2%), and postanalytic phase (2.2%).
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psnet.ahrq.gov/issue/perceptions-impact-large-scale-collaborative-improvement-programme-experience-uk-safer
February 01, 2011 - This mixed methods study evaluates the first phase of the project by soliciting the perceptions of project … Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Description or reactions: The reaction phase includes clearing the air, reviewing the facts, and identifying … Analysis: In this phase, the experience is further explored to enhance learning and new understanding … The goals of this phase are to explore participants’ rationale for observed behaviors,
identify and … Application or Summary: This phase of debriefing is designed to identify and summarize the main learning … During the analysis phase, JA co-develops priorities with the group.
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psnet.ahrq.gov/node/61083/psn-pdf
October 28, 2020 - We are in the eighth year now, and
the second phase of the work. … In the first phase, we worked with 16 nursing facilities in Missouri with high
https://psnet.ahrq.gov … The
second phase of the initiative introduces a billing component. … LP: We're actually writing an article right now for the results of the second phase of the Initiative … We have something like 3000 root cause analysis tools in
Phase 1 and 3500 in Phase 2.
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psnet.ahrq.gov/issue/effectiveness-integrated-health-information-technologies-across-phases-medication-management
October 19, 2022 - Review
The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials.
Citation Text:
McKibbon A, Lokker C, Handler S, et al. The effectiveness of integrated health information technologies a…
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psnet.ahrq.gov/issue/common-contributing-factors-diagnostic-error-retrospective-analysis-109-serious-adverse-event
September 14, 2022 - Using multiple investigative methods supports more targeted interventions in each phase of diagnosis.
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psnet.ahrq.gov/issue/using-four-phased-unit-based-patient-safety-walkrounds-uncover-correctable-system-flaws
October 05, 2022 - Study
Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.
Citation Text:
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39…
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 07, 2019 - During this phase, the facilitator needs to elicit perspectives from team members about how events unfolded … Analysis: In this phase, the experience is further explored to enhance learning and new understanding … The goals of this phase are to explore participants’ rationale for observed behaviors, identify and close … Application or Summary: This phase of debriefing is designed to identify and summarize the main learning … During the analysis phase, JA co-develops priorities with the group.
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - skills.(3)
When used as described above, class-based training offers three advantages in this teaching phase … to train our staff of more than 200 people would have been more than $85,000 for just the teaching
phase … The post-teaching implementation phase consists of several steps. … This reinforces
the KSAs learned during the teaching phase and helps to translate them into clinical … compensated for their time spent on the unit, but
these funds can be taken from monies saved on the teaching phase
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psnet.ahrq.gov/node/861285/psn-pdf
January 24, 2024 - error was reduced after the intervention and, while the
risk increased slightly during the sustainment phase
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psnet.ahrq.gov/issue/preventable-deaths-who-how-often-and-why
February 22, 2011 - The final phase called for developing a screening tool to identify patients at admission who were at
-
psnet.ahrq.gov/node/42315/psn-pdf
June 05, 2013 - special-issue-simulation
https://psnet.ahrq.gov/issue/leaders-and-followers-individual-experiences-during-early-phase-simulation-based-team
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psnet.ahrq.gov/node/852460/psn-pdf
August 16, 2023 - The AHRQ Safety Program for Perinatal Care, Phase 2
developed toolkits consisting of case scenarios,
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psnet.ahrq.gov/issue/radiographers-experience-preventing-patient-safety-incidents-context-radiological
December 20, 2017 - January 18, 2011
Leaders' and followers' individual experiences during the early phase … July 7, 2010
Incident reporting practices in the preanalytical phase: low reported frequencies
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psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients
July 15, 2014 - September 25, 2011
Response of practicing chiropractors during the early phase of the … Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - and (c) post-analytical 2-4 Up to 75% of all medical testing errors occur during the pre-analytical phase … In contrast, during the analytic phase, error rates are far lower. … Examples of errors encountered during the analytic phase typically resides with improper instrument operation … Medical testing error occurs most frequently during the pre-analytic phase. … Risk management in the preanalytical phase of laboratory testing.
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - errors, with an error rate of 78 per 100,000 visits.( 5 ) Errors often occurred in the administration phase … In the case described, several factors contributed to the error at each phase of the medication-use process … In this case, the main contributors to the error during the pharmacist verification and dispensing phase … The main contributors to the error during the administration phase included the lack of a barcode medication … The administration phase is an important area to target for improved drug administration safety.