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Showing results for "process".

8221. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35396/psn-pdf
      September 11, 2009 - applying-hierarchical-task-analysis-medication-administration-errors The authors analyzed the drug administration process … and where in the process errors are likely to occur. 

8222. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35226/psn-pdf
      June 16, 2010 - issue/medical-errors-mandatory-reporting-voluntary-reporting-or-both The author analyzes the reporting process … He suggests that this process will result in underreporting and provides a model for analyzing reporting

8223. 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

8224. 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

8225. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49468/psn-pdf
      December 16, 2004 - The basic purpose of the "Time Out" process is confirmation, but that confirmation, as stipulated in … The process is designed so that, at its conclusion, all of the surgical, https://psnet.ahrq.gov/web-mm … To all appearances in this case, this confirmation process was not systematically performed. … These guideposts, and indeed the accreditation process itself, are intended to help health care organizations … Each step in each process is clearly delineated and understood by all participants, and the roles of

8226. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41692/psn-pdf
      September 19, 2012 - Pharmacists in Canadian community pharmacies had a more positive opinion of a computerized error reporting process … compared with a traditional paper-based process.

8227. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39180/psn-pdf
      December 16, 2009 - description-inpatient-medication-management-using-cognitive-work-analysis This study used cognitive engineering techniques to analyze the process … dispensing, and administration in a hospital, and to develop a framework for improving the safety of the process

8228. 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

8229. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49654/psn-pdf
      June 01, 2012 - Errors can occur in the transfer process at any time—before, during, or after the transfer. … However, other issues can also affect the quality and safety of the transport process, whether it is … Improving Transport Process There are a number of potential means by which the transport process can … Published guidelines highlight the need for clear communication throughout the process, accompanying … In particular, it highlights the safety problems that occur when the process is not standardized and

8230. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33682/psn-pdf
      April 01, 2009 - In the safety process domain, we do have some models that could be used much more effectively than they … Adverse events are different from routine process breakdowns because they represent unique sequences … The reverse is true about process. … You must have a proven relationship of a process to an outcome in order for that process to be a valid … I see that process only intensifying as we create a more effective internal improvement process.

8231. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38324/psn-pdf
      January 14, 2009 - effectiveness-random-and-focused-review-detecting-surgical-pathology-error This study found that a focused review process … detects a higher proportion of surgical pathology errors than a targeted random review process.

8232. Empty Handoff | PSNet
      psnet.ahrq.gov/web-mm/empty-handoff
      August 01, 2017 - 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 … 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 … Handover Processes Construct Pit Stop Practice Principle Handover implementation Process

8233. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33788/psn-pdf
      June 01, 2015 - The process itself can often be very cumbersome. … It's one thing I've paid a lot of attention to since I came here, trying to find ways to make that process … CC: The criteria that we use for endorsement, which is the process that individual measurements and … As we've looked recently at our processes, we realized that, between the endorsement process and the … selection process, we could be much more efficient if the endorsement process were to offer opinions

8234. Urine a Tough Position | PSNet
      psnet.ahrq.gov/web-mm/urine-tough-position
      January 01, 2009 - Clinicians were asked to report any irregularities in the laboratory testing process during a 6-month … However, this process often breaks down. … Primary care practices and testing facilities should take a proactive process redesign approach to the … Clear guidelines for this specimen process should be created and processes audited to ensure compliance … June 9, 2011 Effect of an electronic medication reconciliation application and process

8235. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49607/psn-pdf
      August 01, 2010 - excellent example of an unintended consequence that occurred when a portion of a complex clinical process … For example, a process that involves both shift-change clinicians walking together into each of the … External rules and regulations: The Joint Commission recommends that each organization's: "process for … , and regularly monitored to ensure that the process is working as expected and is safe and effective … technology as well as monitor the percentage of nurses requesting overtime to ensure that the new process

8236. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33691/psn-pdf
      December 01, 2009 - looking at new ways to fix the system, mostly through the introduction of new technologies and system/process … but there are still significant opportunities for improvement.(2-4) Is the barrier poor system or process … We certainly agree that improving system design and process flow will enhance patient safety, but our … Confidential reporting and follow- up are crucial steps in the process. … The process was instituted hospital-wide and was applicable to all hospital staff and physicians.

8237. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49421/psn-pdf
      October 01, 2003 - Clinicians were asked to report any irregularities in the laboratory testing process during a 6- month … However, this process often breaks down. … Primary care practices and testing facilities should take a proactive process redesign approach to the … Clear guidelines for this specimen process should be created and processes audited to ensure compliance … This can allow tracking and trending of errors and further facilitate process redesign based on the

8238. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43898/psn-pdf
      February 11, 2015 - multidisciplinary discussion on how technology, patient engagement, incident reporting, data management, and process … reporting-patient-safety-events https://psnet.ahrq.gov/issue/lost-translation-addressing-barriers-application-industrial-process-improvement-methodologies

8239. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38385/psn-pdf
      February 04, 2009 - of a computerized physician order entry system on nurse-physician collaboration in the medication process … of a computerized physician order entry system on nurse-physician collaboration in the medication process

8240. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47084/psn-pdf
      July 25, 2018 - recognize organizations that have focused on improving anesthesiology medication delivery through process … The award submission process is now closed.