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psnet.ahrq.gov/issue/changes-efficiency-and-safety-culture-after-integration-i-pass-supported-handoff-process
June 25, 2018 - Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process … Changes in Efficiency and Safety Culture After Integration of an I-PASS-Supported Handoff Process. … This study used the I-PASS framework to develop and implement a standardized signout process for transferring … The new process significantly improved clinician workflow and perceived safety culture relating to … Changes in Efficiency and Safety Culture After Integration of an I-PASS-Supported Handoff Process.
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psnet.ahrq.gov/issue/lost-translation-addressing-barriers-application-industrial-process-improvement-methodologies
May 11, 2019 - Addressing barriers in the application of industrial process improvement methodologies to health care … Addressing Barriers in the Application of Industrial Process Improvement Methodologies to Health Care … This commentary describes obstacles to utilizing process improvement techniques from industry in health … Addressing Barriers in the Application of Industrial Process Improvement Methodologies to Health Care
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psnet.ahrq.gov/issue/clearing-error-using-public-deliberation-define-patient-roles-partners-diagnostic-process
September 13, 2016 - Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process … Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process … factors to consider when designing interventions to strengthen patient participation in the diagnostic process … Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process … Medication errors at hospital admission and discharge: risk factors and impact of medication reconciliation process
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psnet.ahrq.gov/issue/henry-ford-production-system-reduction-surgical-pathology-process-misidentification-defects
July 16, 2013 - Study
The Henry Ford Production System: reduction of surgical pathology in-process … misidentification defects by bar code-specified work process standardization. … The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects … by bar code-specified work process standardization. … by bar code-specified work process standardization.
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psnet.ahrq.gov/issue/designing-patient-safety-developing-methods-integrate-patient-safety-concerns-design-process
December 14, 2010 - Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process … Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process … designing health care facilities and includes methods to incorporate these concerns into the design process … Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process
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psnet.ahrq.gov/issue/identifying-health-information-technology-usability-issues-contributing-medication-errors
November 03, 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 … health information technology usability issues contributing to medication errors across medication process
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psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative-case-study
October 07, 2020 - Study
Team experiences of the root cause analysis process after a sentinel event: … Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. … after an RCA investigation to elicit their experiences and assess compliance with the Norwegian RCA process … Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.
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psnet.ahrq.gov/issue/five-topics-health-care-simulation-can-address-improve-patient-safety-results-consensus
June 28, 2023 - Five topics health care simulation can address to improve patient safety: results from a consensus process … Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process … This article describes the consensus process and provides recommendations for patient safety curricula … Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process
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psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational-analysis-findings
July 29, 2020 - incident characterization: an observational analysis of the findings of a standardized peer review process … incident characterization: an observational analysis of the findings of a standardized peer review process … emergency department, researchers investigated incident reports using a standardized peer review process … incident characterization: an observational analysis of the findings of a standardized peer review process
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psnet.ahrq.gov/issue/developing-process-support-tools-patient-safety-finding-balance-between-validity-and
January 20, 2010 - Commentary
Developing process-support tools for patient safety: finding the balance … Developing process-support tools for patient safety: finding the balance between validity and feasibility … describes the conceptual model guiding the Johns Hopkins Quality and Safety Group tool development process … Developing process-support tools for patient safety: finding the balance between validity and feasibility
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psnet.ahrq.gov/issue/resilient-actions-diagnostic-process-and-system-performance
November 13, 2024 - Study
Resilient actions in the diagnostic process and system performance. … Resilient actions in the diagnostic process and system performance. … Resilient actions in the diagnostic process and system performance. … logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process
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psnet.ahrq.gov/issue/implementation-medication-reconciliation-process-ambulatory-internal-medicine-clinic
October 28, 2009 - Study
Implementation of a medication reconciliation process in an ambulatory internal … Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. … The authors conclude that staff and patients need to actively participate in this process. … Implementation of a medication reconciliation process in an ambulatory internal medicine clinic.
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psnet.ahrq.gov/issue/process-changes-increase-compliance-universal-protocol-bedside-procedures
December 01, 2014 - Study
Process changes to increase compliance with the Universal Protocol for bedside … Process changes to increase compliance with the universal protocol for bedside procedures. … A quality improvement process that included forcing functions resulted in significantly improved adherence … Process changes to increase compliance with the universal protocol for bedside procedures.
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psnet.ahrq.gov/issue/improving-discharge-process-embedding-discharge-facilitator-resident-team
January 23, 2019 - Study
Improving the discharge process by embedding a discharge facilitator in a resident … Improving the discharge process by embedding a discharge facilitator in a resident team. … medical team at a tertiary care hospital, with the specific responsibility of facilitating the discharge process … Although NP discharge facilitation achieved improved patient satisfaction with the discharge process, … Improving the discharge process by embedding a discharge facilitator in a resident team.
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psnet.ahrq.gov/issue/care-transitions-outpatient-surgery-preoperative-process-facilitators-and-obstacles
December 31, 2014 - Study
Care transitions in the outpatient surgery preoperative process: facilitators … Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information … This AHRQ-funded study describes one organization’s efforts to detail its preoperative process around … Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information
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psnet.ahrq.gov/issue/development-emergency-department-trigger-tool-using-systematic-search-and-modified-delphi
August 30, 2017 - Development of an emergency department trigger tool using a systematic search and modified Delphi process … Development of an Emergency Department Trigger Tool Using a Systematic Search and Modified Delphi Process … Their Delphi process resulted in a 46-item proposed tool that will require validation and testing in … Development of an Emergency Department Trigger Tool Using a Systematic Search and Modified Delphi Process … incident characterization: an observational analysis of the findings of a standardized peer review process
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psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older
November 15, 2023 - Study
Information management goals and process failures during home visits for middle-aged … Information management goals and process failures during home visits for middle-aged and older adults … The authors recommend redesigning the care transition process from hospital to home health care providers … Information management goals and process failures during home visits for middle-aged and older adults
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psnet.ahrq.gov/issue/implementing-safer-and-more-reliable-system-monitor-test-results-teaching-university
November 07, 2018 - results at a teaching university-affiliated facility in a family medicine group: a quality improvement process … results at a teaching university-affiliated facility in a family medicine group: a quality improvement process … This article describes use of the AHRQ toolkit Improving Your Office Testing Process to implement new … Providers and patients were satisfied with the new process. … results at a teaching university-affiliated facility in a family medicine group: a quality improvement process
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psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event-reporting-and-care
December 29, 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 … Researchers implemented a Web-based electronic medication error reporting system in concert with a novel work process … Impact of a reengineered electronic error-reporting system on medication event reporting and care process … November 16, 2015
Evaluating inpatient mortality: a new electronic review process that
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psnet.ahrq.gov/issue/effects-teamwork-training-adverse-outcomes-and-process-care-labor-and-delivery-randomized
January 10, 2017 - Classic
Effects of teamwork training on adverse outcomes and process … Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized … result in improvement in patient (maternal or fetal) clinical outcomes or in the delivery of appropriate process … Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized … intervention to improve communication and patient safety in obstetrics: examination of the health action process