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psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures
November 01, 2023 - Newspaper/Magazine Article
Patient death tied to lack of proper escalation process … Citation Text:
Patient death tied to lack of proper escalation process for barcode scanning failures … Cite
Citation
Citation Text:
Patient death tied to lack of proper escalation process … May 20, 2020
Near-miss event analysis enhances the barcode medication administration process
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psnet.ahrq.gov/issue/diagnostic-stewardship-leveraging-laboratory-improve-antimicrobial-use
March 15, 2023 - This commentary suggests that adjusting the diagnostic testing process could enhance the reliability … 2015
Developing electronic clinical quality measures to assess the cancer diagnostic process … results at a teaching university-affiliated facility in a family medicine group: a quality improvement process … Reduction in hospital-wide clinical laboratory specimen identification errors following process
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psnet.ahrq.gov/issue/ambulatory-medication-reconciliation-using-collaborative-approach-process-improvement
December 04, 2019 - Study
Ambulatory medication reconciliation: using a collaborative approach to process … Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academic … Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academic … May 29, 2019
Assessing information sources to elucidate diagnostic process errors in … January 29, 2019
A web application to involve patients in the medication reconciliation process
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psnet.ahrq.gov/issue/resident-led-institutional-patient-safety-and-quality-improvement-process
November 16, 2022 - Study
A resident-led institutional patient safety and quality improvement process … A resident-led institutional patient safety and quality improvement process. … A resident-led institutional patient safety and quality improvement process. … February 17, 2009
Teaching the diagnostic process as a model to improve medical education
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psnet.ahrq.gov/issue/medication-reconciliation-improvement-utilizing-process-redesign-and-clinical-decision
November 16, 2022 - Study
Medication reconciliation improvement utilizing process redesign and clinical … Medication Reconciliation Improvement Utilizing Process Redesign and Clinical Decision Support. … Medication Reconciliation Improvement Utilizing Process Redesign and Clinical Decision Support.
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psnet.ahrq.gov/issue/technology-based-closed-loop-tracking-improving-communication-and-follow-pathology-results
May 25, 2022 - This study explored whether RFID technology can improve process measures in laboratory settings, such … Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones … March 11, 2020
Patient and clinician experiences of uncertainty in the diagnostic process … Reduction in hospital-wide clinical laboratory specimen identification errors following process
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psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action
June 22, 2022 - between the National Center for Patient Safety (NCPS) and Veterans Affairs (VA) facilities in the RCA process … The authors review current monitoring efforts and contrast the RCA process with the now-replaced focused … review process. … Following detailed presentation of these study findings, two actual cases are reviewed to describe the RCA process
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
March 09, 2022 - Study
Healthcare failure mode and effect analysis in the chemotherapy preparation process … Healthcare failure mode and effect analysis in the chemotherapy preparation process. … Healthcare failure mode and effect analysis in the chemotherapy preparation process. … and Criticality Analysis to improve safety in the cancer treatment prescription and administration process … 29, 2017
Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process
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psnet.ahrq.gov/issue/equipment-related-incidents-operating-room-analysis-occurrence-underlying-causes-and
February 14, 2024 - the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process … the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process … the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process … , 2011
Quality and safety on an acute surgical ward: an exploratory cohort study of process
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psnet.ahrq.gov/issue/clinical-informatics-team-members-perspectives-health-information-technology-safety-after
September 04, 2024 - members' perspectives on health information technology safety after experiential learning and safety process … members' perspectives on health information technology safety after experiential learning and safety process … members' perspectives on health information technology safety after experiential learning and safety process … December 19, 2018
Developing a learning health system: insights from a qualitative process
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psnet.ahrq.gov/issue/standardized-assessment-medication-reconciliation-post-acute-care
December 16, 2020 - Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient … elements may provide the means for post-acute care settings to assess and improve this important quality process … Related Resources From the Same Author(s)
Transforming the medication regimen review process … December 22, 2021
Transforming the medication regimen review process using telemedicine
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Approach
The “waste”, or safe disposal, of medications is an integral step in the medication-use process … the right drug, the right dose, the right route, and the right time. 9 However, the medication-use process … 21%. 3
APSF also encourages administrators to work with vendors to augment their medication-use process … This process would allow an independent party to verify the use of the product against the record, as … Conclusion
The lack of a standardized process for wasting of medications in the perioperative setting
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psnet.ahrq.gov/issue/developing-electronic-clinical-quality-measures-assess-cancer-diagnostic-process
December 18, 2024 - Developing electronic clinical quality measures to assess the cancer diagnostic process … Developing electronic clinical quality measures to assess the cancer diagnostic process. … Developing electronic clinical quality measures to assess the cancer diagnostic process. … Study
Catching those who fall through the cracks: integrating a follow-up process
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems … used among patients who died. e-Biopsy denotes the non-mortality eB methodology review process. … After the review process is completed, the data from the review tool are analyzed by the eA/eB team, … Multiple systemic problems were found from the three-part process for each diagnosis. … This process facilitates continuous buy-in from organizational staff.
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - map diagram with main process steps
and sub-steps depicting how the flow of outpatient blood draws … and revealing failure modes within the
process.2
Description of Innovation
The NCPS developed CPRA … and mapping all events, reactive
risk assessments, and adverse events to every process bucket to bring … CPRA involves a 4-step process. … The flow diagram summarizes the process and
reveals a list of all failure modes.
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psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
September 13, 2021 - Failure Mode and Effect Analysis (FMEA)
September 13, 2021
Anonymous (not verified)
A common process … used to prospectively identify error risk within a particular process. … FMEA begins with a complete process mapping that identifies all the steps that must occur for a given … With the process mapped out, the FMEA then continues by identifying the ways in which each step can go … Different teams charged with analyzing the same process may identify different steps in the process,
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - map diagram with main process steps and sub-steps depicting how the flow of outpatient blood draws and … revealing failure modes within the process. 2
Description of Innovation
The NCPS developed CPRA … and mapping all events, reactive risk assessments, and adverse events to every process bucket to bring … CPRA involves a 4-step process. … The flow diagram summarizes the process and reveals a list of all failure modes.
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psnet.ahrq.gov/issue/systemic-failures-health-care-oversight
July 05, 2006 - This article suggests a shift in the process of collecting data on clinician performance from a voluntary … process focusing on blame to a required generic record. … Accordingly, the process would become more reliable, accountability would be focused on the organization … July 24, 2024
DOD Should Improve Its Process for Clinical Adverse Actions against Providers
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psnet.ahrq.gov/issue/getting-it-right-patient-safety-specimen-collection-process-improvement-operating-room
July 16, 2013 - Commentary
Getting it right for patient safety: specimen collection process improvement … Getting It Right for Patient Safety: Specimen Collection Process Improvement From Operating Room to … Getting It Right for Patient Safety: Specimen Collection Process Improvement From Operating Room to … July 16, 2013
The Henry Ford Production System: reduction of surgical pathology in-process … misidentification defects by bar code-specified work process standardization.
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psnet.ahrq.gov/node/866905/psn-pdf
October 09, 2024 - Dual process models of clinical reasoning: the central
role of knowledge in diagnostic expertise. … Dual process models of clinical reasoning: the central role of
knowledge in diagnostic expertise. … https://psnet.ahrq.gov/issue/dual-process-models-clinical-reasoning-central-role-knowledge-diagnostic … https://psnet.ahrq.gov/issue/dual-process-models-clinical-reasoning-central-role-knowledge-diagnostic-expertise … https://psnet.ahrq.gov/issue/dual-process-models-clinical-reasoning-central-role-knowledge-diagnostic-expertise