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Showing results for "processes".

181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866621/psn-pdf
     August 28, 2024 - A goal of the Safety-I framework is to implement processes and procedures to prevent the recurrence … Safety-II seeks to understand and replicate processes that allow things to go right most of the time … This model to assess processes and adverse events has been used in settings such as intensive care, … events, where patients have a good outcome, to understand what led to that outcome and replicate those processes … Learning teams may or may not be triggered by a safety incident; the goal is to examine processes from

182. Strategies and Approaches for Investigating Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
     March 15, 2025 - The concept of Root Cause Analysis and Action (RCA2) emphasizes that the processes of analyzing and … a structured adverse event analysis tool that aims to prospectively identify potential failures in processes … after they have occurred, FMEA focuses on engaging health care team members in analyzing and modifying processes … to prevent medication errors , assessing blood transfusion processes to prevent morbidity and mortality … from transfusion errors, and restructuring hospital policies and processes to prevent patient falls.

183. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
     January 01, 2024 - death or severe morbidity. 11 11 Overview (2) We are not computers: Our fundamental cognitive processes … without fear of disrespect or retribution.2 Such collaboration should now be ingrained into hospital processes … 18 EHRs and Cognitive Processes (1) Lack of communication was probably compounded by a cognitive failure … Our understanding of the influence of electronic health records (EHRs) on clinicians' cognitive processes … that we are far from ideal practices in efficiently capitalizing on EHRs to optimize our cognitive processes

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60867/psn-pdf
     September 02, 2020 - from the root cause analyses to characterize the contributing system failures and key activities and processes … The most common key processes involved in these events were diagnostic and procedural services, and

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73509/psn-pdf
     July 21, 2021 - Common action themes include reviewing organizational processes and highlighting appropriate guidelines … https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837308/psn-pdf
     June 01, 2022 - Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was

187. The Future of NHS Patient Safety Investigation. | PSNet
     psnet.ahrq.gov/issue/future-nhs-patient-safety-investigation
     April 18, 2018 - Organizational processes to investigate adverse care incidents play an important part in generating … Serious Incident Framework, used by the National Health Service, to enhance reporting and investigation processes

188. Overcoming COVID-19: what can human factors and ergonomics offer? | PSNet
     psnet.ahrq.gov/issue/overcoming-covid-19-what-can-human-factors-and-ergonomics-offer
     September 02, 2020 - The authors discuss Just-in-time (JIT) training, adapting workflow processes, identifying potential … failure modes and safety hazards, and revisions to protocols and processes to provide safe care to patients

189. Comparison of military and civilian methods for determining potentially preventable deaths: a systematic review. | PSNet
     psnet.ahrq.gov/issue/comparison-military-and-civilian-methods-determining-potentially-preventable-deaths
     October 19, 2022 - The authors note widely varying review processes, data inclusion, and preventability assessment , and … recommend standardization of definitions and processes in order to reduce bias.

190. Emotional harm in the radiology department: analysis of an underrecognized preventable error. | PSNet
     psnet.ahrq.gov/issue/emotional-harm-radiology-department-analysis-underrecognized-preventable-error
     March 06, 2019 - proposed several improvement strategies, including communication training and improvement of communication processes … , individual feedback, and improvements to existing processes and systems.

191. Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout. | PSNet
     psnet.ahrq.gov/issue/measuring-and-improving-diagnostic-safety-primary-care-addressing-twin-pandemics-diagnostic
     September 07, 2022 - proposed a new framework of diagnostic process safety to measure the quality and safety of diagnostic processes … February 8, 2023 Implementation of patient safety structures and processes in the patient-centered

192. Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime. | PSNet
     psnet.ahrq.gov/issue/anatomy-cyberattack-part-4-quality-assurance-and-error-reduction-billing-and-compliance
     April 27, 2022 - cyberattack led to a 25-day shutdown of a hospital’s EHR that necessitated a rapid shift to manual processes … This article outlines the laboratory service’s processes during the shutdown, including patient safety

193. When COVID-19 hit, many elderly were left to die. | PSNet
     psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
     June 24, 2020 - This story examines the weakness of care processes in nursing homes in Europe that have been revealed … September 2, 2020 From tasks to processes: the case for changing health information technology

194. Algorithmic prediction of failure modes in healthcare. | PSNet
     psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthcare
     September 06, 2023 - Failure mode and effect analysis (FMEA) is used to asses risk in various heath care processes. … Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes

195. Physician gender and apologies in clinical interactions. | PSNet
     psnet.ahrq.gov/issue/physician-gender-and-apologies-clinical-interactions
     July 07, 2021 - preferred female physicians to make emotion-based apologies and male physicians to apologize based on the processes … The "Seven Pillars" response to patient safety incidents: effects on medical liability processes

196. All CLEAR? Preparing for IT downtime. | PSNet
     psnet.ahrq.gov/issue/all-clear-preparing-it-downtime
     November 16, 2022 - Due to the increasing integration of health care processes with information technology, unavailability … May 3, 2016 From tasks to processes: the case for changing health information technology

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846935/psn-pdf
     March 29, 2023 - The AIM program has led the development of patient safety bundles that provide structured processes … Selecting a screening tool for use in the clinical setting, as well as developing processes and protocols … After a positive screening result, processes should be in place for determining safety and for referring … Mental Health As highlighted by the patient safety bundles and clinical guidelines, developing robust processes … Outlining and enacting processes for follow-up and referral in case of a positive screening can ensure

198. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet
     psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
     April 19, 2023 - May 26, 2021 Deficiencies in Inpatient Mental Health Care Coordination and Processes … May 26, 2021 Deficiencies in Inpatient Mental Health Care Coordination and Processes … December 23, 2012 Evaluation of Registered Nurse Competency Processes in Veterans Health

199. Blackbox error management: how do practices deal with critical incidents in everyday practice? A qualitative interview study. | PSNet
     psnet.ahrq.gov/issue/blackbox-error-management-how-do-practices-deal-critical-incidents-everyday-practice
     May 01, 2024 - Respondents described critical incidents across a spectrum, from organizational processes to medical … December 7, 2022 Systems engineering analysis of diagnostic referral closed-loop processes

200. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74230/psn-pdf
     January 12, 2022 - registered-nurses-perceptions-safe-care-overcrowded-emergency-departments https://psnet.ahrq.gov/issue/identifying-safe-care-processes-when-gps-work-or-alongside-emergency-departments-realist … https://psnet.ahrq.gov/issue/identifying-safe-care-processes-when-gps-work-or-alongside-emergency-departments-realist