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psnet.ahrq.gov/node/60338/psn-pdf
May 20, 2020 - application-strong-matrix-management-and-pdca-cycle-management-severe-
covid-19-patients
This article describes the use of strong matrix management and the plan-do-check-act … patients
https://pubmed.ncbi.nlm.nih.gov/10107388/
https://psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
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psnet.ahrq.gov/node/43054/psn-pdf
June 16, 2014 - face-to-face
communication between doctors and nurses declined, and there was less agreement about the plan … we-need-talk-observational-study-impact-electronic-medical-record-implementation-hospital
https://psnet.ahrq.gov/issue/patterns-nurse-physician-communication-and-agreement-plan-care … exploring-sociotechnical-intersection-patient-safety-and-electronic-health-record
https://psnet.ahrq.gov/issue/hospitalized-patients-understanding-their-plan-care
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psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - It also included discharge resources (including a self-administered safety plan) and post-ED telephone … Getting Started with This Innovation
The innovators found that a deployment plan was necessary when … A deployment plan lays out the step-by-step process for implementing the innovation. … For example, the deployment plan may include metrics that track whether the innovation is being adopted … For example, the innovator discovered via their deployment plan that the screener was not being used
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psnet.ahrq.gov/node/47993/psn-pdf
May 15, 2019 - This
commentary outlines how one hospital used Plan–Do–Study–Act cycles to improve their MRI screening … analysis-and-prioritization-near-miss-adverse-events-radiology-department
https://psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
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psnet.ahrq.gov/node/854262/psn-pdf
October 04, 2023 - This commentary
outlines elements supporting engagement as part of an ambitious global plan and awareness … what-happened-patient-safety
https://psnet.ahrq.gov/issue/request-comment-draft-global-patient-safety-action-plan
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psnet.ahrq.gov/node/849328/psn-pdf
May 24, 2023 - resources are also available, such as from the Institute for Healthcare Improvement
National Action Plan … using-safety-culture-results-guide-merger-four-general-practices-uk
https://psnet.ahrq.gov/issue/crico
https://psnet.ahrq.gov/issue/national-action-plan-advance-patient-safety
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psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients
April 17, 2024 - The article shares recommendations drawn from a national action plan to enable effective response to … Interview
In Conversation With...Amy Helwig about Health Plan
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psnet.ahrq.gov/issue/quality-and-patient-safety-teams-perioperative-setting
October 19, 2022 - This commentary describes how one organization designed and implemented a team-focused plan to enhance … safe perioperative practice and explores the benefits of strategies like daily rounds , plan-do-study-act
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psnet.ahrq.gov/node/50883/psn-pdf
February 12, 2020 - This article describes Plan-Do-Study-Act processes employed in the acute care cardiology unit of a
large … reducing-safety-hazards-monitor-alert-and-alarm-fatigue
https://psnet.ahrq.gov/issue/systematic-review-application-plan-do-study-act-method-improve-quality-healthcare
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psnet.ahrq.gov/issue/high-prevalence-medication-discrepancies-between-home-health-referrals-and-centers-medicare
December 23, 2011 - home health referrals and Centers for Medicare and Medicaid Services home health certification and plan … Home Health Referrals and Centers for Medicare and Medicaid Services Home Health Certification and Plan … Home Health Referrals and Centers for Medicare and Medicaid Services Home Health Certification and Plan
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Discharge planners can be “gate keepers” to ensure
patients have established treatment/monitoring plan … 13
Necessary Components of OPAT Plan:
• Care plan with discharge location
• IV antibiotic order … hospital
– Monitors weekly laboratory orders/values and clinical
status of infection
– Coordinate plan … to discharge
18
OPAT Team Members:
• Discharge Planner
– Guarantee adequate review of discharge plan … have been placed
– Ensure appropriate communication and documentation
of transition of care and OPAT plan
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psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety
April 01, 2024 - systems, federal partners, patients and families , and other stakeholders to implement a national plan … Request for comments on the proposed measures and 2020 targets for the National Action Plan
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psnet.ahrq.gov/node/865658/psn-pdf
April 24, 2024 - admitted, then prior to admission, the facility is required to complete a written Needs and Services
Plan … The LPA will typically evaluate the Needs and Services Plan of that resident to determine whether the … If it is determined that the staff member ignored
the plan and performed the transfer that required … Another way that a facility can be cited or be required to implement a Plan of Correction is if it is … and possibly dehydration if not addressed.6 These side effects should have been noted in the
care plan
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psnet.ahrq.gov/issue/safer-together-survey-advancing-patient-and-workforce-safety
July 12, 2017 - Steering Committee for Patient Safety (NSC) was formed to engage with the health care community to plan … from the field to determine current interest and status in efforts aligned with the National Action Plan
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psnet.ahrq.gov/node/74178/psn-pdf
December 15, 2021 - day-to-day operations; and encouraging the use of
patient safety strategies outlined in the National Action Plan … issue/peer-review-report-strategies-improve-patient-safety
https://psnet.ahrq.gov/issue/national-action-plan-advance-patient-safety
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - risk after non-cardiac surgery
3
TOO MANY COOKS IN THE KITCHEN
A case describing deviations in the plan … shortening
operative time
17
Approach to Improving Safety (4)
• Failure to modify a surgical plan … fixation errors include ruling out the
worst-case scenario, accepting that the first assumption or plan … • Once the plan is developed for such a patient, it is important
to follow it as prescribed. … Take-Home Points (2)
28
• Optimal care of frail patients hinges on a plan with the least
possible
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psnet.ahrq.gov/issue/interventions-engage-patients-and-families-patient-safety-systematic-review
March 04, 2020 - interventions involving both information and involvement (e.g., use of decision aids to determine care plan … Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan
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psnet.ahrq.gov/issue/world-federation-chiropractic-global-patient-safety-task-force-call-action
December 23, 2020 - It organizes its approach on the elements of the WHO Global Patient Safety Action Plan to position … March 15, 2023
National Plan for Health Workforce Well-Being.
-
psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - Using this information, they work with the hospital to create a work plan intended to
advance care improvement … This work plan is
specific to the hospital and focused on a few specific priorities. … the NQP team is able to help the hospital identify where it is doing well in progressing the
work plan … The hospital work plan is a living document and is expected to be updated as goals are achieved.
… Ensure a plan for data collection and analysis that allows for
regular identification of potential areas
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psnet.ahrq.gov/node/845360/psn-pdf
March 29, 2023 - assessing a
patient’s functional cognitive status and using their functional status to inform the care plan … screen, track, and
monitor patients along a cognition continuum, make proactive changes to the care plan