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Showing results for "processes".

281. Medication Administration Errors | PSNet
     psnet.ahrq.gov/primer/medication-administration-errors
     December 15, 2024 - 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 … 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 … Audits of the administration process not only validate adherence to protocols but may highlight system processes

282. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
     August 28, 2024 - This may be precipitated by a safety event, but the intent is to look at processes through the eyes of … You don't need engineers or complex processes to do it. … A goal of the Safety-I framework is to implement processes and procedures to prevent the recurrence of … Safety-II seeks to understand and replicate processes that allow things to go right most of the time … Learning teams may or may not be triggered by a safety incident; the goal is to examine processes from

283. Application of Safety-II Principles | PSNet
     psnet.ahrq.gov/perspective/application-safety-ii-principles
     August 28, 2024 - A goal of the Safety-I framework is to implement processes and procedures to prevent the recurrence of … Safety-II seeks to understand and replicate processes that allow things to go right most of the time … Learning teams may or may not be triggered by a safety incident; the goal is to examine processes from … This may be precipitated by a safety event, but the intent is to look at processes through the eyes of … You don't need engineers or complex processes to do it.

284. The long road to patient safety: a status report on patient safety systems. | PSNet
     psnet.ahrq.gov/issue/long-road-patient-safety-status-report-patient-safety-systems
     October 04, 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

285. How reliable are clinical systems in the UK NHS? A study of seven NHS organisations. | PSNet
     psnet.ahrq.gov/issue/how-reliable-are-clinical-systems-uk-nhs-study-seven-nhs-organisations
     November 26, 2008 - 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 one

286. Protocol-based computer reminders, the quality of care and the non-perfectability of man. | PSNet
     psnet.ahrq.gov/issue/protocol-based-computer-reminders-quality-care-and-non-perfectability-man
     April 24, 2018 - confirmed that computerized decision support systems improve physician performance at a variety of processes … January 12, 2011 The effects of on-screen, point of care computer reminders on processes

287. Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach. | PSNet
     psnet.ahrq.gov/issue/operating-room-icu-patient-handovers-multidisciplinary-human-centered-design-approach
     June 27, 2012 - suggest that their human factors-based improvement approach could be applied to other patient safety processes … July 5, 2023 Care transition of trauma patients: processes with articulation work before

288. Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient handoffs. | PSNet
     psnet.ahrq.gov/issue/analyzing-and-mitigating-risks-patient-harm-during-operating-room-intensive-care-unit-patient
     October 05, 2022 - 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

289. Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. | PSNet
     psnet.ahrq.gov/issue/prevalence-and-characteristics-diagnostic-error-pediatric-critical-care-multicenter-study
     December 11, 2024 - cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes … March 23, 2022 Care transition of trauma patients: processes with articulation work before

290. Artificial intelligence, bias and clinical safety. | PSNet
     psnet.ahrq.gov/issue/artificial-intelligence-bias-and-clinical-safety
     September 23, 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

291. Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care. | PSNet
     psnet.ahrq.gov/issue/greater-focus-credentialing-needed-prevent-disqualified-providers-delivering-patient-care
     September 25, 2019 - April 27, 2016 View More Related Resources Defense Health Agency Processes … February 3, 2016 VA Health Care: Improvements Needed in Processes Used to Address Providers

292. A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units. | PSNet
     psnet.ahrq.gov/issue/human-factors-engineering-conceptual-framework-nursing-workload-and-patient-safety-intensive
     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

293. An observational study of postoperative handoff standardization failures. | PSNet
     psnet.ahrq.gov/issue/observational-study-postoperative-handoff-standardization-failures
     March 10, 2021 - cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes … April 6, 2022 Care transition of trauma patients: processes with articulation work before

294. Patient safety and end-of-life care: common issues, perspectives, and strategies for improving care. | PSNet
     psnet.ahrq.gov/issue/patient-safety-and-end-life-care-common-issues-perspectives-and-strategies-improving-care
     June 30, 2021 - Related Resources From the Same Author(s) Implementation of patient safety structures and processes … The "Seven Pillars" response to patient safety incidents: effects on medical liability processes

295. SEIPS 3.0: human-centered design of the patient journey for patient safety. | PSNet
     psnet.ahrq.gov/issue/seips-30-human-centered-design-patient-journey-patient-safety
     September 11, 2019 - 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

296. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. | PSNet
     psnet.ahrq.gov/issue/seips-20-human-factors-framework-studying-and-improving-work-healthcare-professionals-and
     February 16, 2022 - Related Resources From the Same Author(s) Care transition of trauma patients: processes … cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes

297. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33589/psn-pdf
     September 15, 2024 - Sometimes people interpret high reliability as meaning effective standardization of health care processes … Reluctance to Simplify People resist simplifying their understanding of work processes and how and … workflows to reduce variation, they also appreciate the complexity inherent in the number of teams, processes

298. Organizational learning: health care leaders need to design structures and processes that enhance collective learning. | PSNet
     psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
     November 18, 2020 - Commentary Organizational learning: health care leaders need to design structures and processes

299. Safety of inpatient care in surgical settings: cohort study. | PSNet
     psnet.ahrq.gov/issue/safety-inpatient-care-surgical-settings-cohort-study
     May 15, 2024 - 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

300. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33831/psn-pdf
     April 01, 2017 - 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 … Together with our RPI program, that reorientation has driven our accreditation processes to be much … 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.