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Showing results for "process".

9981. 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

9982. 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

9983. 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.

9984. 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

9985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38881/psn-pdf
      November 08, 2012 - are-patients-part-blame-when-doctors-miss-diagnosis This column recounts a case of delayed diagnosis and examines how communication and process … psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis

9986. 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

9987. 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

9988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40419/psn-pdf
      October 21, 2011 - issue/ismp-medication-safety-self-assessment-hospitals This tool provides hospitals with a team-based process … The data submission process is now closed, but the survey is still available for in-house use.

9989. 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. 

9990. 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

9991. 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.

9992. 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

9993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49750/psn-pdf
      January 01, 2016 - https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned … The nurse completed the usual check-in process later in the evening but did not contact the admitting … Many might assume that a direct, planned admission is an uncomplicated process. … Thus, at first glance a direct admission seems to be a systematic process. … Responsible for communicating with patients about the admission process.

9994. 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

9995. 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.

9996. 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

9997. An Untimely End Despite End-of-Life Care Planning | PSNet
      psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
      February 01, 2012 - 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 … in performance, and specify which tasks can be delegated.( 11 ) In our institution, we created the process … The Huddle uses a checklist ( Figure and Table ) to guide the process, individualizing it for each … Preventing errors during the complex process of withdrawing life-saving therapies requires structured

9998. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
      January 01, 2016 - Objectives At the conclusion of this educational activity, participants should be able to: Review a common process … The nurse completed the usual check-in process later in the evening but did not contact the admitting … appropriately 9 9 Direct Admissions: Processes Involved (2) Directly admitting a patient is a complex process … the hospital Nurses have reported improved sense of control over their workload after using a LEAN process … consequences Clear understanding of the limitations of the electronic tool as well as the workflow process

9999. 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.

10000. Transfer Troubles | PSNet
       psnet.ahrq.gov/web-mm/transfer-troubles
       December 29, 2014 - Errors can occur in the transfer process at any time—before, during, or after the transfer. … At all stages of the transfer process, communication appeared to be inadequate. … 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