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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
June 02, 2025 - Assess how organizational culture influences
health IT and patient safety
29
30
Development Process … Training (3 items)
• EHR System Support and Communication
(3 items)
• EHR and Workflow/Work Process … EHR Workflow/Work Process
42
EHR and Workflow/Work Process
Comments
43
“Need more portable workstations … EHR System Support & Communication
EHR System Support & Communication Comments
EHR Workflow/Work Process … EHR and Workflow/Work Process Comments
EHR Overall Rating
EHROverall Rating Comments
Health IT Patient
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-7-implementation-guide.pdf
June 02, 2025 - the process and be ready
to answer questions or respond to objections. … and intervene to
correct the process. … ■ Monitor AR process for behavior changes and examine user-level
data. … assessing the process, if change is slow, until the changes are
completed … • Incorporate care coordination into automatic referral process.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
January 01, 2024 - They also underscored the importance of cross-cutting process improvement work in diagnostic safety. … Graber, et al. 8
Diagnostic Error
Any mistake or failure in the diagnostic process leading to … . 63 The Tripartite Framework of Diagnostic Process Safety proposed to measure quality and safety of … 67,68 and the testing process. 69
3.2.3. … process.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - for MRSA Prevention | Surgical Services
Learning From Defects
1
Educational Objectives
Describe a process … (CUSP) Learning From Defects (LFD) tools and resources
Work through an example of a defect and the process … MRSA Prevention | Surgical Services
Learning From Defects
4
Purpose of the Learning From Defects Process … The LFD process is continuous. … The LFD process enables teams to look at the system surrounding the defects and the underlying causes
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
October 01, 2024 - Program for MRSA Prevention | ICU & Non-ICU
Learning From Defects
1
Educational Objectives
Describe a process … (CUSP) Learning From Defects (LFD) tools and resources
Work through an example of a defect and the process … | 8
AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU
Learning From Defects
LFD Process: What … | 12
AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU
Learning From Defects
LFD Process: Why … The LFD process is continuous.
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www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
January 01, 2024 - It is the first study to apply ST-PRA to the community pharmacy dispensing process. … and Control System Map
The research team created a process and control map of the dispensing process … This more closely models the process in one of the two participating
chain pharmacies. … The essence of business process re-engineering. … Process modeling. Commun ACM. 1992;35(9):75-90.
82 Oakland JS.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sca-key-drive-diagram.pdf
June 02, 2025 - Process to support massed appointments.
Holiday or birthday cards with t c d reminders. … Standardized process for obtaining prior authorizations
Preventative care patient education
Standardized … Process for clinic to create notarized care plans to identify
authorized caregivers. … Develop process and data collection tools. … Reliable process for
obtaining medications.
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www.ahrq.gov/sites/default/files/2024-07/stock-easton-report.pdf
January 01, 2024 - practices process
design. … if the process was in control. … that process in control for
the same period. … part of process improvement. … • Stakeholder ownership in the process and development is critical.
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www.ahrq.gov/sites/default/files/2025-02/silver2-report.pdf
January 01, 2025 - The risk model was developed using process mapping, input from home health
subject matter experts (SME … reliability ST-PRA risk modeling
– Process mapping – Process mapping
– Reliability engineering, human … The review process considered:
1. Time (in days) from start of care to hospitalization
2. … Agencies noted the value
of this process in highlighting recognized issues. … The Behavior-Based Safety Process (2nd Ed.).
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/pqmp-data-process-flow.pdf
June 02, 2025 - Step 3: Practice reviews key practice-wide process
measure performance. … Step 3: Practice reviews key practice-
wide process measure performance
Step 2: Chart review of at least … Step 3: Practice reviews key practice-
wide process measure performance. … This process flow map assumes that
the sponsor of this Phase 2 “deep
dive” effort provides quality
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology3.html
April 01, 2025 - Thus, diagnosis can refer to the label applied to a patient’s condition or the process or activities … to arrive at that label (e.g., to diagnose, diagnosing, diagnostic process). 5 As these perspectives … illustrate, the term can be either a noun or verb, a conclusion or process. 6 Judgments about the … correctness or adequacy of a diagnostic label or process can also change over time as science informs
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
May 01, 2024 - between increasing cognitive load and decreasing diagnostic accuracy are cognitive overload and dual-process … occurs when working memory becomes overly burdened, leading to a decreased ability to learn, accurately process … interrupted or asked to perform two simultaneous tasks extraneous to their primary task, they have to process … Cognitive Load and Dual-Process Thinking Cognitive load also directly impacts dual-process thinking. … Cognitive load directly affects clinicians’ ability to engage in dual-process thinking.
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www.ahrq.gov/teamstepps-program/curriculum/implement/pre/measure.html
January 01, 2024 - Measurement is the process of classifying based on the characteristics of an object or action. … Continued implementation and sustainability: Measures are used to assess process and outcome changes … Other process measures may make a stronger case for TeamSTEPPS than any of the measures noted above. … : (after the trainings)
What process and outcome measures would be of most concern? … when gathering data on these process and outcome measures?
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www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
January 01, 2024 - ED)
operational and quality management characteristics and to identify and implement generalizable process … An FMECA elicits information about any
failures for each step in a process including the underlying … The scope of the FMECA was the process of ED management of patients with STEMI. … Six steps of
the FMECA process were completed. … Additional process improvements
included developing a standard process for changing intravenous lines
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-situation-monitoring.pptx
January 10, 2022 - (TeamSTEPPS for Office-Based Care: Situation Monitoring, 2015)
5
Slide
Process of actively scanning … Situation monitoring is important across each step of the diagnostic process.
… One way to address the breakdowns and improve team effectiveness is to use a cross-monitoring process … The STEP process is a mnemonic tool that can help team members monitor the situation and the overall … The STEP process involves ongoing monitoring of the:
Status of the patient: What are the patient’s
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-presenters-notes.pdf
January 10, 2022 - Situation monitoring is important across each step of the diagnostic process. … [Image source: National Academy of Medicine conceptualization of the diagnostic
process, 2015.] … Slide 9
STEP Process for
Situation Monitoring
One approach that helps with situation monitoring … is to use the STEP process. … The STEP process involves ongoing monitoring of the:
• Status of the patient: What are the patient’s
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-presenters-notes.pdf
January 12, 2022 - Image Source: National Academy of Medicine conceptualization of the diagnostic
process, 2015. … How do they contribute to the diagnostic process? Front desk personnel?
Clinic nurse? … Do they know their role in the process? … Act in ways that can
contribute to the
diagnostic process. … • ACT: in ways that can contribute to the diagnostic process.
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module2-team-structure.pptx
January 12, 2022 - Image Source: National Academy of Medicine conceptualization of the diagnostic process, 2015.
5
Slide … How do they contribute to the diagnostic process? Front desk personnel? Clinic nurse? Pharmacist?
… Do they know their role in the process? … Act in ways that can contribute to the diagnostic process. … ACT: in ways that can contribute to the diagnostic process.
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www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
January 01, 2024 - Pre-implementation surveillance
was conducted to establish baseline process failure rates. … These meetings
served to uncover process failures and to develop measures to prevent these failures. … Multiple caregivers can
be involved in the process of carrying out an order. … Not surprisingly, the process failures identified in these meetings corresponded to the gaps in care … Medication Delivery Process Overview (Site A) [large arrows represent gaps in the process]
Figures 2
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion.pptx
April 01, 2022 - 3,6
Promotes standardized supplies and insertion process
Reduces potentially harmful variations in care … Build the new process, prepare staff, and conduct the pilot. … Act Adopt, abandon, or revise the process. Educate all staff on use of CVC insertion checklist. … Amount of products stocked on the unit
In-unit process for ensuring supplies are available
Business … hours versus after-hours and weekends process (if different)
AHRQ Safety Program for ICUs: Preventing