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Showing results for "processes".

261. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49687/psn-pdf
     August 21, 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 … Increasing evidence supports interventions that improve the reliability of care processes for emergency … Basic processes of care for these patients are frequently incomplete or omitted.

262. Multifactorial Medication Mishap | PSNet
     psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
     September 01, 2016 - weaknesses in the system and corrective plans should include risk reduction strategies that span multiple processes … Quality Processes and Risk Management Lastly, more robust quality control processes may reduce the … such as failure mode and effects analysis (FMEA), will help institutions ensure that new medications, processes … Use proactive risk assessment tools whenever new medications, processes, and services are implemented … errors • Encouragement of patient input n quality improvement and safety initiatives Quality processes

263. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43788/psn-pdf
     February 25, 2015 - surveyed administrators about organizational safety and staff about communication and existing safety processes … Respondents also reported weaknesses in outpatient referral processes.

264. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43157/psn-pdf
     May 07, 2014 - Governing board, C-suite, and clinical management perceptions of quality and safety structures, processes … Governing board, C-suite, and clinical management perceptions of quality and safety structures, processes

265. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. | PSNet
     psnet.ahrq.gov/issue/learning-preventable-deaths-exploring-case-record-reviewers-narratives-using-change-analysis
     June 17, 2014 - contributing factors and enabled more in-depth understanding about underlying problems related to care processes … Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes

266. Fatal flaws in clinical decision making. | PSNet
     psnet.ahrq.gov/issue/fatal-flaws-clinical-decision-making
     March 03, 2011 - to perform surgery and that retrospectively reviewing deaths for such CDMIs may supplement existing processes … 2020 Creating a high-reliability health care system: improving performance on core processes

267. Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy. | PSNet
     psnet.ahrq.gov/issue/diffusion-surgical-innovations-patient-safety-and-minimally-invasive-radical-prostatectomy
     June 06, 2008 - examine 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

268. Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys. | PSNet
     psnet.ahrq.gov/issue/evaluating-ambulatory-practice-safety-promises-project-administrators-and-practice-staff
     August 14, 2017 - surveyed administrators about organizational safety and staff about communication and existing safety processes … Respondents also reported weaknesses in outpatient referral processes.

269. Establishing an ambulatory medicine quality and safety oversight structure: leveraging the fractal model. | PSNet
     psnet.ahrq.gov/issue/establishing-ambulatory-medicine-quality-and-safety-oversight-structure-leveraging-fractal
     July 01, 2017 - safety improvement programs in the ambulatory setting is challenging due to variations in outpatient processes … 2017 Creating a high-reliability health care system: improving performance on core processes

270. The critical incident technique. | PSNet
     psnet.ahrq.gov/issue/critical-incident-technique
     January 07, 2015 - technique," the history of its evolution dating back to World War II, and its success in analyzing processes … 2019 The effect of providing staff training and enhanced support to care homes on care processes

271. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49607/psn-pdf
     August 01, 2010 - "(1) Therefore, when communication processes change from synchronous to asynchronous, one must ensure … New technologies seek to improve, as measured in the broadest sense, on existing processes. … Therefore, the designer and implementer must not only understand the existing processes' strengths and … People: When technology-driven processes replace previous face-to-face communication processes, the … Potential errors resulting from replacing existing human-based processes with new technology must be

272. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet
     psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
     March 01, 2017 - others, especially when errors occur [ 2 ]); systems orientation (members recognize that people and processes … Align systems and processes. Inertia is a powerful force. … To make change stick, critical organizational processes must support and reinforce desired behaviors. … ( 9 ) Budgeting, hiring, performance management, and monitoring and control processes all signal the … Systems and processes are often the responsibility of managers, but frontline clinicians can also play

273. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
     June 01, 2013 - seniority may reduce the risk of errors associated with emergency surgery Describe how variability in processes … situations, prompt diagnosis and care is essential Several studies have demonstrated poor adherence to basic processes … antibiotics Prescription of thromboprophylaxis Observation of patients’ vital signs Omission of basic care processes … Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit … Basic processes of care for these patients are frequently incomplete or omitted.

274. Second opinions improve healthcare outcomes and reduce costs. | PSNet
     psnet.ahrq.gov/issue/second-opinions-improve-healthcare-outcomes-and-reduce-costs
     April 12, 2023 - cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes … January 15, 2020 Care transition of trauma patients: processes with articulation work

275. DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers. | PSNet
     psnet.ahrq.gov/issue/dod-and-va-health-care-medication-needs-during-transitions-may-not-be-managed-all
     December 09, 2020 - December 9, 2020 Veterans Health Care: Veterans Health Administration Processes for Responding … December 1, 2022 Deficiencies in Inpatient Mental Health Care Coordination and Processes

276. Through and beyond anaesthesia awareness. | PSNet
     psnet.ahrq.gov/issue/through-and-beyond-anaesthesia-awareness
     September 20, 2023 - January 31, 2024 Psychological safety during the test of new work processes in an emergency … April 18, 2011 No simple fix for fixation errors: cognitive processes and their clinical

277. Exploring performance obstacles of intensive care nurses. | PSNet
     psnet.ahrq.gov/issue/exploring-performance-obstacles-intensive-care-nurses
     March 11, 2020 - cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes … June 22, 2022 Care transition of trauma patients: processes with articulation work before

278. One Toxic Drug Is Not Like Another | PSNet
     psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
     October 02, 2019 - Case Objectives Distinguish between the three distinct regulatory processes of board certification … Appreciate how emerging maintenance-of-certification and licensure processes address physician competence … Turning back to certification, a fair question is whether current certification processes truly make … The processes and dimensions of informed self-assessment: a conceptual model. … Regulatory Processes in Physician Practice.  

279. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33605/psn-pdf
     March 12, 2021 - These five “rights” have been historically incorporated into the nursing curriculum as the standard processes … causes of medication administration errors may include inadequate training, distractors, convoluted processes … misconfiguration.2 Despite error reduction efforts through implementing new technologies and streamlining processes … nurses to intercept errors prior to administration with key high-alert medications.4 Double check processes … workload, these double checks should be strategically targeted to the highest-risk medications and processes

280. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73106/psn-pdf
     April 01, 2021 - //#2 https://psnet.ahrq.gov//#2 Histograms can also help users identify potential improvements in processes … Specifically, the control chart highlights which peaks suggest out-of-control processes rather than … CLABSI rates in May-20 and Feb-21 were above the UCL, prompting an evaluation of the structures and processes … The run chart: a simple analytical tool for learning from variation in healthcare processes.