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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - HFE interventions commonly focus on people, tools, technology, procedures, and processes. … As healthcare systems, technology, and processes increase in complexity, HFE approaches were designed … A shared mental model means that cross-functional teams are in alignment with the steps and processes … We’re also interested in designing processes and the physical environment. … those processes.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4a_pdi01-lacerationpuncture-bestpractices.pdf
May 31, 2016 - Best Processes/Systems of Care
Introduction: Essential First Steps
• Engage key nurses, physicians … • Evaluate effectiveness of new processes, determine gaps, modify processes as needed, and
reimplement … Additional Resources
Systems/Processes
• Centers for Disease Control and Prevention. … Selected Best Practices and Suggestions for Improvement
PDI 01: Accidental Puncture or Laceration
Best Processes … disposal
Educational Recommendation
Effectiveness of Action Items
Additional Resources
Systems/Processes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4o_combo_pdi01-lacerationpuncture-bestpractices.pdf
May 31, 2016 - Best Processes/Systems of Care
Introduction: Essential First Steps
• Engage key nurses, physicians … • Evaluate effectiveness of new processes, determine gaps, modify processes as needed, and
reimplement … Additional Resources
Systems/Processes
• Centers for Disease Control and Prevention. … Best Processes/Systems of Care
Introduction: Essential First Steps
Recommended Practice: Appropriate … disposal
Educational Recommendation
Effectiveness of Action Items
Additional Resources
Systems/Processes
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psnet.ahrq.gov/node/40928/psn-pdf
May 04, 2012 - Decision-making processes used by nurses during
intravenous drug preparation and administration. … Decision-making processes used by nurses during intravenous drug
preparation and administration. … https://psnet.ahrq.gov/issue/decision-making-processes-used-nurses-during-intravenous-drug-preparation … https://psnet.ahrq.gov/issue/decision-making-processes-used-nurses-during-intravenous-drug-preparation-and-administration … https://psnet.ahrq.gov/issue/decision-making-processes-used-nurses-during-intravenous-drug-preparation-and-administration
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psnet.ahrq.gov/node/39156/psn-pdf
April 17, 2011 - Understanding interdisciplinary health care teams: using
simulation design processes from the Air Carrier … Understanding interdisciplinary health care teams: using
simulation design processes from the Air Carrier … ://psnet.ahrq.gov/issue/understanding-interdisciplinary-health-care-teams-using-simulation-design-
processes-air … https://psnet.ahrq.gov/issue/understanding-interdisciplinary-health-care-teams-using-simulation-design-processes-air … https://psnet.ahrq.gov/issue/understanding-interdisciplinary-health-care-teams-using-simulation-design-processes-air
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psnet.ahrq.gov/issue/quality-and-safety-acute-surgical-ward-exploratory-cohort-study-process-and-outcome
March 03, 2011 - This study found that compliance with specific care processes was poor and that risk for adverse events … Related Resources From the Same Author(s)
Effect of a "Lean" intervention to improve safety processes … Effectiveness of facilitated introduction of a standard operating procedure into routine processes … October 4, 2011
Effect of a "Lean" intervention to improve safety processes and outcomes
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
June 01, 2023 - Recommended approaches and sample processes to consider are based on these types of procedures. … This worksheet includes some common approaches for incorporating these processes in your pathway, but … However, it is important to try to adhere to as many of the processes as possible. … Higher rates of adherence to a more comprehensive bundle of enhanced recovery processes is associated … Pathway
Component
Example Processes To Consider
As a team, go through each component and discuss what
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psnet.ahrq.gov/node/36338/psn-pdf
October 26, 2010 - Work practice, work
processes and utopian views of automatic drug
dispensing systems. … Work practice, work processes and
utopian views of automatic drug dispensing systems. … https://psnet.ahrq.gov/issue/who-charge-patient-safety-work-practice-work-processes-and-utopian-views … https://psnet.ahrq.gov/issue/who-charge-patient-safety-work-practice-work-processes-and-utopian-views-automatic-drug … https://psnet.ahrq.gov/issue/who-charge-patient-safety-work-practice-work-processes-and-utopian-views-automatic-drug
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www.ahrq.gov/patient-safety/settings/hospital/match/intro.html
July 01, 2022 - Although this toolkit is based on processes developed in acute-care settings, the core processes, tools … While many health care providers already have medication reconciliation processes in place, this toolkit … present a systematic methodology for critically reviewing and improving the medication reconciliation processes
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www.ahrq.gov/es/patient-safety/settings/hospital/match/intro.html
July 01, 2022 - Although this toolkit is based on processes developed in acute-care settings, the core processes, tools … While many health care providers already have medication reconciliation processes in place, this toolkit … present a systematic methodology for critically reviewing and improving the medication reconciliation processes
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psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined
August 10, 2022 - computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes … Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare … Effectiveness of facilitated introduction of a standard operating procedure into routine processes
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psnet.ahrq.gov/node/42963/psn-pdf
September 27, 2016 - The effects of physical environments in medical wards on
medication communication processes affecting … The effects of physical environments in medical wards on medication
communication processes affecting … https://psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-
processes-affecting … https://psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting … https://psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting
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www.ahrq.gov/ncepcr/reports/primary-care-research/appendix-a.html
January 01, 2024 - , safety
Healthcare Themes
Clinical Decision-making (Y/N) defined as Decision support tools or processes … that processes/organizes/prioritizes information (pt or general) allow a clinician to make a care decision … These tools or processes may interpret or integrate evidence/data and be integral in suggesting next … Care Management [Coordination/Transitions in Care] (Y/N) defined as people or processes in the workflow … are needed to ensure continuity of care such as navigator or social worker; includes technology or processes
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psnet.ahrq.gov/issue/veterans-health-care-veterans-health-administration-processes-responding-reported-adverse
August 15, 2012 - Book/Report
Veterans Health Care: Veterans Health Administration Processes for Responding … Citation Text:
Veterans Health Care: Veterans Health Administration Processes for Responding to Reported … Citation
Citation Text:
Veterans Health Care: Veterans Health Administration Processes … October 10, 2012
Evaluation of Registered Nurse Competency Processes in Veterans Health
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psnet.ahrq.gov/node/46226/psn-pdf
October 29, 2017 - Eliciting the functional processes of apologizing for
errors in health care: developing an explanatory … Eliciting the Functional Processes of Apologizing for Errors in Health Care:
Developing an Explanatory … https://psnet.ahrq.gov/issue/eliciting-functional-processes-apologizing-errors-health-care-developing … https://psnet.ahrq.gov/issue/eliciting-functional-processes-apologizing-errors-health-care-developing-explanatory-model … https://psnet.ahrq.gov/issue/eliciting-functional-processes-apologizing-errors-health-care-developing-explanatory-model
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psnet.ahrq.gov/node/38779/psn-pdf
July 15, 2009 - Prospective risk analysis of health care processes: a
systematic evaluation of the use of HFMEA in Dutch … Prospective risk analysis of health care processes:
a systematic evaluation of the use of HFMEA in Dutch … https://psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use … https://psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use-hfmea-dutch-health … https://psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use-hfmea-dutch-health
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psnet.ahrq.gov/node/42862/psn-pdf
January 15, 2014 - VA Health Care: Improvements Needed in Processes
Used to Address Providers' Actions That Contribute … https://psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-
actions-contribute … expert interviews from four Veterans Affairs medical centers to identify weaknesses in peer review
processes … https://psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute … https://psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20141022_cg/2_mon_yee.pdf
June 02, 2025 - Research Corporation
• Clinic manager reviews scores with staff
and provider
• Scores posted
17
Processes … Visit Survey Top-Box Scores to the National 90th Percentiles
Implementation and Use of CGCAHPS
Processes
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides2.html
October 01, 2017 - Slide 14: Assess Current Pressure Injury Processes
Understand current processes in patient care … Use process mapping to examine key processes (Tool 2C). … Do the care processes follow best practices? … Point out key processes being used.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - HFE interventions commonly focus on people, tools,
technology, procedures, and processes. … all work system
elements (including people) can go right or wrong, HFE uses human-centered design processes … As
healthcare systems, technology, and processes increase in complexity, HFE approaches were designed … A shared
mental model means that cross-functional teams are in alignment with the steps and processes … HFE offers an essential path
forward to navigating that complexity to build safe processes and outcomes