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Showing results for "process".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49463/psn-pdf
     October 14, 2004 - One in a Series of Errors In this example, as in most such cases, a series of errors occurred in the process … Next, the nurse failed to correctly identify the patient when she began the medication administration process … (Figure 1) A bar code medication administration process, in which nurses scan a medication, the patient … number of hospitals that have successfully implemented bar coding into the medication administration process … is small in comparison to those that are planning or in the process of implementation.

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45694/psn-pdf
     June 15, 2017 - Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process … Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process … Researchers found that adherence to 18 out of 19 care process measures improved after the checklist

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39813/psn-pdf
     October 11, 2010 - Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process … Veterans Affairs (VA) Medical Team Training program improves the cardiopulmonary resuscitation code process … tool and postcode discussions have guided identification and resolution of issues in the CPR code process

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43401/psn-pdf
     August 02, 2015 - psnet.ahrq.gov/issue/morning-handover-call-issues-opportunities-improvement The safety of the signout process … Comparatively less attention has been paid to the morning signout process, when the primary clinician … behavior—illustrates the role of shared responsibility between the primary and covering physicians in the signout process

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45976/psn-pdf
     December 21, 2017 - medications to inpatient clinicians upon hospital admission via an electronic medication reconciliation process … pharmacist–generated gold standard medication list to the actual medications ordered during an admission after such a process … medication-reconciliation https://psnet.ahrq.gov/issue/effect-electronic-medication-reconciliation-application-and-process-redesign-potential

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43419/psn-pdf
     October 20, 2014 - Impact of a reengineered electronic error-reporting system on medication event reporting and care process … Impact of a reengineered electronic error-reporting system on medication event reporting and care process … implemented a Web-based electronic medication error reporting system in concert with a novel work process

467. Cutting-edge efforts in surgical patient safety. | PSNet
     psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
     August 02, 2015 - Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process … February 2, 2022 Implementing a robust process improvement program in the neonatal intensive … the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process … , 2010 Quality and safety on an acute surgical ward: an exploratory cohort study of process

468. Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. | PSNet
     psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures
     January 03, 2017 - ward staff engage with the implementation of a patient safety intervention: a UK-based qualitative process … August 17, 2018 The process and perspective of serious incident investigations in adult … 22, 2021 Healthcare failure mode and effect analysis in the chemotherapy preparation process … 20, 2019 Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40675/psn-pdf
     November 28, 2016 - in-depth interviews with 100 patients who experienced errors, and went through the error disclosure process … to evaluate the perception of patients (and their families) of the disclosure process. … Patients consistently stated that how errors were disclosed affected their feelings about the process

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38229/psn-pdf
     November 18, 2016 - QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process … QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process … In 2015, the SQUIRE guidelines were revised through a process that included semistructured interviews

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37838/psn-pdf
     June 11, 2008 - mitigation-patient-harm-testing-errors-family-medicine-offices-report-american- academy-family Patient harm resulting from errors in the diagnostic testing process … However, as noted in prior research, problems were noted at each stage of the testing process, implying … frequency-missed-test-results-and-associated-treatment-delays-highly-computerized-health https://psnet.ahrq.gov//#nearmiss https://psnet.ahrq.gov/issue/testing-process-errors-and-their-harms-and-consequences-reported-family-medicine-practices

472. In Conversation With... John G. Reiling, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
     June 01, 2014 - The third principle is to change the facility design process to focus on safety. … We took a Lean view of this process and created a continuous flow. … The fundamental thing is to create a process where people wash their hands. … I think it's one of the most interesting cultural, process, and cognitive issues because we have such … JR : I'd like to talk about the importance of the architectural process—that the design process itself

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49838/psn-pdf
     August 01, 2018 - Communicating how symptoms will be managed during the process and ensuring all team members know the … goals of the patient and family prepares the team for the process of life-sustaining therapies withdrawal … The Huddle uses a checklist (Figure and Table) to guide the process, individualizing it for each patient … anticipated patient trajectory; and discussion of challenges that may arise during the withdrawal process … Preventing errors during the complex process of withdrawing life-saving therapies requires structured

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49664/psn-pdf
     January 01, 2013 - For example, in changing the handoff process, we demonstrated that a standardized process is less reliant … We found that our method—which involves a clear process division between handoff preparation, equipment … have now been replicated by others (Table and Figure).(10,13) The performance gains included less process … The ability to detect, avoid, and manage errors should be considered in any design of a handoff process … Safety checks built into process Prediction of future patient needs and likely risks Overview and

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49473/psn-pdf
     March 01, 2005 - If the patient and/or family had been actively engaged during the care process, this error would have … The care process here favors "action" despite clear and compelling reasons to hold- off. … Once again, the motivation behind the ragged process revolved around time-saving goals. … The ideal process to have prevented this error would have been a clear model of communication with patient … A structured process for adding and canceling cases with the OR would have confirmed the cancellation

476. Moved Too Soon | PSNet
     psnet.ahrq.gov/web-mm/moved-too-soon
     November 01, 2006 - One in a Series of Errors In this example, as in most such cases, a series of errors occurred in the process … Next, the nurse failed to correctly identify the patient when she began the medication administration process … coding is finding new applications in patient care.( Figure 1 ) A bar code medication administration process … number of hospitals that have successfully implemented bar coding into the medication administration process … is small in comparison to those that are planning or in the process of implementation.

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49556/psn-pdf
     March 01, 2008 - From a physician standpoint, the desire to temporarily stop a medication is common, and the process … Yet errors that arise with hold orders may occur during all phases of the medication-use process. … For example, breakdowns that occur during the transcribing or data entry process, as documented by the … PA-PSRS, include: Transcribing process When hold orders, or the parameters for the hold order, are … In ambulatory practice settings, prescribers should establish a process to track medications they wanted

478. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
     June 01, 2005 - RCA—Differential Diagnosis No nursing guidelines or protocols for use of vasopressor medications No process … in the ICU for reviewing key aspects of patient care during daily rounds ICU physician rounding process … the use of vasopressors No systematic review of medication doses during nursing sign-out No regular process … right drug is being given to right patient at the right dose RCA—Differential Diagnosis No process … RCA—System Solutions Redesign medication delivery process employing multidisciplinary approach Reconcile

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33790/psn-pdf
     August 01, 2015 - .(4-6) Integrating formative usability testing into the development process is critical to successful … matter experts may result in a functional order writing system, but a strong user- centered design process … systems, abnormal findings and change in a patient's status are easily missed during the discharge process … This process of supporting the cognitive needs of the user in health care is further complicated by the … These efforts must leave adequate time for testing the systems during the development process, and should

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49733/psn-pdf
     May 01, 2015 - The transfer from pediatric to adult care is, indeed, a point in the transition process, but it takes … In this vignette, there were failures of two processes: the process of transitioning the patient to … prepare her for the future as an adult with congenital heart disease, and the process of transfer to … This preparation includes discussion of the changing role of the parents during the transfer process … Ensure that the disease care and preparation during the transfer process are actively coordinated and