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Showing results for "process".

401. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet
     psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
     November 16, 2022 - From an HFE perspective, care transitions are a process that spans two distinct work systems. … The design process is a continuous improvement process. Sarah Mossburg: Dr. … We were able to create this new process within the admission process and the electronic health record … What other key challenges did you experience as part of this process? … Pascale Carayon: I can speak about the one we did on the extended discharge process.

402. People, processes, health IT and accurate patient identification. | PSNet
     psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
     April 11, 2018 - Newspaper/Magazine Article People, processes, health IT and accurate patient identification. Citation Text: People, processes, health IT and accurate patient identification. Quick Safety. October 1, 2018;(45):1-2. Copy Citation Save Save to your library Prin…

403. Requirements for the design and implementation of checklists for surgical processes. | PSNet
     psnet.ahrq.gov/issue/requirements-design-and-implementation-checklists-surgical-processes
     September 25, 2008 - Review Requirements for the design and implementation of checklists for surgical processes. Citation Text: Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, et al. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc. 2009;23(4):715-26. doi:10.10…

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73446/psn-pdf
     June 30, 2021 - comprehensive-departmental-care-review-model-requirements-structure-and- flow Peer review can provide clinicians an opportunity to learn from failure, but the process … The authors outline the care review process, which includes direct care staff feedback; single provider … comprehensive-departmental-care-review-model-requirements-structure-and-flow https://psnet.ahrq.gov/issue/clinical-perspective-creating-effective-practice-peer-review-process-primer

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73465/psn-pdf
     July 07, 2021 - health information technology usability issues contributing to medication errors across medication process … health information technology usability issues contributing to medication errors across medication process … reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72799/psn-pdf
     March 03, 2021 - The authors of this perspective proposed a new framework of diagnostic process safety to measure the … framework can provide a structured approach for designing and testing specific measures of diagnostic process … and-diagnostic-error https://psnet.ahrq.gov/issue/assessing-information-sources-elucidate-diagnostic-process-errors-radiologic-imaging-human

407. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50651/psn-pdf
     November 13, 2019 - This systematic review assessed the relationship between teamwork processes and clinical and process … Outcome measures included both clinical outcomes, such as postoperative infection rates, and process … The authors found that teamwork was positively correlated with both outcome and process measures, regardless

408. Triaging Interhospital Transfers | PSNet
     psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
     April 12, 2023 - Realize that the interhospital transfer process is vulnerable to deficiencies in communication that can … potential tool for improving the exchange of clinical information during the interhospital transfer process … research is needed to establish best practice guidelines with regard to the interhospital transfer process … In the presented case, the transferring physician was not aware of any formal process to transfer his … Such streamlining often involves simplifying and standardizing both the transfer request process for

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46728/psn-pdf
     March 27, 2018 - Near-miss event analysis enhances the barcode medication administration process. … https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration- process … https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-process … https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-process

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72784/psn-pdf
     February 24, 2021 - nurses in diagnosis), addressing system factors, and strategies for engaging patients in the diagnostic process … learning-patients-experiences-related-diagnostic-errors-essential-progress-patient-safety https://psnet.ahrq.gov/issue/what-if-transforming-diagnostic-research-leveraging-diagnostic-process-map-engage-patients … https://psnet.ahrq.gov/issue/what-if-transforming-diagnostic-research-leveraging-diagnostic-process-map-engage-patients

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49563/psn-pdf
     May 01, 2008 - /psnet.ahrq.gov/web-mm/it-safe-be-direct https://psnet.ahrq.gov//#references The direct admission process … Potential for errors and delays abound in this multi-tiered process. … While some PCPs may overuse the direct admission process to help their patients avoid the chaos of the … Revamping the process would not only address the safety issues but also improve patient throughput by … Take-Home Points Steps to improve the direct admission process include: Simplify the process by eliminating

412. In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
     November 16, 2022 - The design process is a continuous improvement process. Sarah Mossburg: Dr. … We were able to create this new process within the admission process and the electronic health record … What other key challenges did you experience as part of this process? … Pascale Carayon: I can speak about the one we did on the extended discharge process. … From an HFE perspective, care transitions are a process that spans two distinct work systems.

413. Strategies and Approaches for Investigating Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
     March 15, 2025 - in an FMEA is to assemble a team of individuals with a range of knowledge and experience about the process … The team then conducts detailed process mapping to identify all the steps in the process that is being … One this is done, “failure modes”, i.e., ways in which a process or product could potentially fail or … variables, provides a quantitative estimate of the level of hazard involved in various steps of the process … Using this approach, components of the process or product most in need of change are identified , and

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34802/psn-pdf
     January 01, 2016 - 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

415. Total Parenteral Nutrition, Multifarious Errors | PSNet
     psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
     January 23, 2017 - Describe the PN-use process. Identify potential PN-related medication errors. … Even though the ingredients in PN may carry some risk, errors in the PN-use process may lead to even … , and the hospital should have a standardized process to reduce the risk for errors. … .( 20 ) The final steps in the PN-use process are administration of PN and ongoing monitoring. … actions taken to improve the process.

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33823/psn-pdf
     January 01, 2017 - It describes a repeatable process and structure that, we believe, can lead to improved safety in a variety … This Job Safety Behavioral Observation process for health care uses tools and methodologies common in … for each process step and a way to eliminate them. … After discussion with surgeons performing this procedure we changed the pick process such that only … Surgical scheduling: a lean approach to process improvement. AORN J. 2014;99:147-159.

417. Systems Approach | PSNet
     psnet.ahrq.gov/primer/systems-approach
     June 15, 2024 - FMEA begins with identifying all the steps that must occur for a given process to occur. … Once this process mapping is complete, the FMEA then continues by identifying the ways in which each … The estimates of the likelihood of a particular process failure, the chance of detecting such failure … Each step in this process would be assigned a probability of failure and an impact score, so that all … Different teams charged with analyzing the same process may identify different steps in the process,

418. Discharge Planning and Transitions of Care | PSNet
     psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
     June 15, 2024 - care increase the risk of readmissions and adverse drug events after discharge. 1 The discharge process … literacy or current health status. 3 Prior studies have shown that an early discharge preparation process … help provide evidence-based training for staff as well as outline processes to improve the discharge process … and reduce readmissions. 9 Nurses play an integral role in the discharge process by coordinating care … A multidisciplinary discharge timeout checklist improves patient education and captures discharge process

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37372/psn-pdf
     August 06, 2008 - Hospitals look to improve informed consent process. August 6, 2008 O'Reilly KB. … https://psnet.ahrq.gov/issue/hospitals-look-improve-informed-consent-process This article discusses … https://psnet.ahrq.gov/issue/hospitals-look-improve-informed-consent-process https://psnet.ahrq.gov//

420. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37421/psn-pdf
     February 15, 2011 - Prescription for error: process defects in a community retail pharmacy. … https://psnet.ahrq.gov/issue/prescription-error-process-defects-community-retail-pharmacy This study … https://psnet.ahrq.gov/issue/prescription-error-process-defects-community-retail-pharmacy