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Showing results for "processes".

241. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/865308
     January 01, 2024 - Curated Library Foundations Organizational learning: health care leaders need to design structures and processes … https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance … Learning health systems (LHS) build functions, networks, and processes to use data, information, evidence … Learning health systems (LHS) build functions, networks, and processes to use data, information, evidence … Organizational learning: health care leaders need to design structures and processes that enhance collective

242. Do some surgical implants do more harm than good? | PSNet
     psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
     January 14, 2011 - This feature discusses  industry  processes that reduce the reliability of surgical implants , including … January 14, 2011 The nurse's experience of decision-making processes in missed nursing

243. Medical Malpractice and Errors. | PSNet
     psnet.ahrq.gov/issue/medical-malpractice-and-errors
     June 19, 2019 - December 23, 2012 From tasks to processes: the case for changing health information technology … May 13, 2019 From tasks to processes: the case for changing health information technology

244. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/73848
     July 01, 2022 - implemented a comprehensive unit-based safety program (CUSP) to improve safety culture and perinatal care processes … Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork … https://psnet.ahrq.gov/issue/integrated-approach-reduce-perinatal-adverse-events-standardized-processes-interdisciplinary … implemented a comprehensive unit-based safety program (CUSP) to improve safety culture and perinatal care processes … Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork

245. Tough Call: Addressing Errors From Previous Providers | PSNet
     psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
     July 17, 2024 - Describe two examples of well-defined processes to identify individual accountability for adverse events … learning.( 9 ) Organizations can reinforce these professional duties by: (i) developing well-defined processes … In addition, organizations should strive to build processes for assessing the extent to which systems … These processes, focused on individual performance and designed to promote professional accountability … , must proceed in parallel with systems-levels processes to reduce the risk of future errors.

246. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45803/psn-pdf
     March 27, 2017 - combining-systems-and-teamwork-approaches-enhance-effectiveness-safety-improvement https://psnet.ahrq.gov/issue/do-team-processes-really-have-effect-clinical-performance-systematic-literature-review … https://psnet.ahrq.gov/issue/do-team-processes-really-have-effect-clinical-performance-systematic-literature-review

247. Can we make postoperative patient handovers safer? A systematic review of the literature. | PSNet
     psnet.ahrq.gov/issue/can-we-make-postoperative-patient-handovers-safer-systematic-review-literature
     June 10, 2015 - This review summarizes how standardizing processes, completing urgent clinical tasks prior to information … July 5, 2023 Care transition of trauma patients: processes with articulation work before

248. Simulation, mastery learning and healthcare. | PSNet
     psnet.ahrq.gov/issue/simulation-mastery-learning-and-healthcare
     November 09, 2011 - individual and system levels and suggests that it can be enhanced with simulation to engineer effective processes … July 13, 2010 Processes for identifying and reviewing adverse events and near misses

249. Obstacles to research on the effects of interruptions in healthcare. | PSNet
     psnet.ahrq.gov/issue/obstacles-research-effects-interruptions-healthcare
     April 19, 2017 - suggests that research about interruptions clearly determine definitions, data collection methods, and processes … 2017 The effects of physical environments in medical wards on medication communication processes

250. In Conversation With… Mark Chassin, MD, MPP, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
     April 26, 2023 - Today, because our clinical care processes are so fraught with weaknesses and failure points, most of … Blameless acts are very common because we put people in broken processes where it's hard to avoid errors … Solving those problems with Lean, improving the outcomes of processes with Six Sigma, and then wrapping … You can do it on the administrative processes. … If they aren't at zero harm in their most critical processes, they keep going until they get there.

251. Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital. | PSNet
     psnet.ahrq.gov/issue/clarifying-radiologys-role-safety-events-5-year-retrospective-common-cause-analysis-safety
     November 21, 2017 - 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 the

252. In pursuit of quality and safety: an 8-year study of clinical peer review best practices in US hospitals. | PSNet
     psnet.ahrq.gov/issue/pursuit-quality-and-safety-8-year-study-clinical-peer-review-best-practices-us-hospitals
     April 13, 2017 - Peer review processes are frequently touted as a means for improving health care quality and safety … The "Seven Pillars" response to patient safety incidents: effects on medical liability processes

253. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33604/psn-pdf
     December 15, 2024 - developing risk- specific protocols for high-alert medications; identifying and evaluating high-risk processes … data; evaluating and implementing new medication technologies; and fostering robust error reporting processes … The complexity of the medication prescribing and delivery processes can make it difficult to prove the

254. Emergency Error | PSNet
     psnet.ahrq.gov/web-mm/emergency-error
     January 18, 2013 - Describe how variability in processes of care can increase the risk to patients undergoing emergency … Variability in outcomes is likely to reflect variable processes of care. … Several studies have demonstrated very poor adherence to basic clinical and organizational processes … Basic processes of care for these patients are frequently incomplete or omitted. … Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41325/psn-pdf
     October 06, 2016 - survey of seven National Health Service hospitals found poor task reliability across several clinical processes … Some hospitals did achieve higher reliability, and the authors cite standardization of processes as

256. Government Response to the Investigation into the Death of Elizabeth Dixon. | PSNet
     psnet.ahrq.gov/issue/government-response-investigation-death-elizabeth-dixon
     February 19, 2020 - 2022 The effect of providing staff training and enhanced support to care homes on care processes … Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes

257. Diagnostic Delay in the Emergency Department | PSNet
     psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
     September 18, 2024 - and weight restrictions of diagnostic imaging tests (e.g., CT scanning).( 5 ) Furthermore, abdominal processes … However, we know very little about clinicians' thought processes in such cases. … This case highlights how a focus on basic clinical skills, cognitive processes, and team-based care is … Modeling the impact of changing patient flow processes in an emergency department: insights from a computer … Health Information Technology Use for Improving Providers' Cognitive Processes ( 27 ) Assist

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43346/psn-pdf
     August 02, 2015 - whether the introduction of a new medical device, the da Vinci robot, led to a change in surgical processes … This finding emphasizes the need to create safety processes and monitoring when novel devices and procedures

259. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41047/psn-pdf
     November 26, 2014 - The review also found wide variation in processes for handling test results across studies. … The authors advocate for more standardized processes for informing patients of abnormal results, and

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35572/psn-pdf
     February 03, 2011 - use of data in patient safety programs, drug administration and safety procedures, error reporting processes … For instance, surgical areas and medication processes seemed to embrace the greatest level of patient