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psnet.ahrq.gov/node/862126/psn-pdf
February 07, 2024 - Using a human factors
and ergonomics approach based on the SEIPS model, this study explored the work processes … authors discuss the role of staffing and
workload, equipment/space design and function, escalation processes
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psnet.ahrq.gov/issue/using-inpatient-portal-engage-families-pediatric-hospital-care
September 13, 2023 - March 11, 2020
Care transition of trauma patients: processes with articulation work before … cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes … Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes
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psnet.ahrq.gov/issue/work-system-barriers-and-facilitators-inpatient-care-transitions-pediatric-trauma-patients
September 11, 2019 - September 11, 2019
Care transition of trauma patients: processes with articulation work … cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes … Nicole Werner, PhD
November 16, 2022
Care transition of trauma patients: processes
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psnet.ahrq.gov/issue/challenges-and-opportunities-improving-patient-safety-through-human-factors-and-systems
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 … January 30, 2019
From tasks to processes: the case for changing health information technology
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psnet.ahrq.gov/node/865483/psn-pdf
April 03, 2024 - solutions in analog (pathway including at least one non-digital step) and fully digital medication
processes … In both processes, experts identified that the most critical risk of errors and harm occurs at
admission
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/dementia-nursing-home-characteristics_executive.pdf
October 01, 2012 - Processes of care refer to what is
actually done in giving and receiving care, and include
programs … Processes of Care
Evidence for group activity interventions was mixed. … Regarding processes of care, evidence for group activity
interventions was mixed. … Regarding processes of care, evidence for group activity
interventions was mixed. … Low
Processes of Care Processes of Care Functional
skill training vs. no such
training
Function was
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psnet.ahrq.gov/node/836990/psn-pdf
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
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psnet.ahrq.gov/node/73637/psn-pdf
August 25, 2021 - care-coordination-strategies-and-barriers-during-medication-safety-incidents-qualitative
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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digital.ahrq.gov/ahrq-funded-projects/impact-office-based-e-prescribing-prescribing-processes-and-outcomes/annual-summary/2010
January 01, 2010 - Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes - 2010
Project … Name
Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes
Principal … researchers to develop a qualitative study demonstrating the impact of e-prescribing on prescribing processes … functions: safety alerts and dispensed drug history. ( Ongoing )
Measure the effect of e-prescribing on processes
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digital.ahrq.gov/ahrq-funded-projects/impact-office-based-e-prescribing-prescribing-processes-and-outcomes/annual-summary/2011
January 01, 2011 - Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes - 2011
Project … Name
Impact of Office-Based E-Prescribing on Prescribing Processes and Outcomes
Principal … researchers together to develop a qualitative study demonstrating the impact of e-prescribing on prescribing processes … (Achieved)
Measure the effect of e-prescribing on processes of prescribing for physicians to assess
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psnet.ahrq.gov/issue/governing-board-c-suite-and-clinical-management-perceptions-quality-and-safety-structures
July 14, 2010 - 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 … Governing board, C-suite, and clinical management perceptions of quality and safety structures, processes
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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
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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.
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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
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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
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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
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psnet.ahrq.gov/node/837308/psn-pdf
June 01, 2022 - Policies and processes
(e.g., lack of standardized processes, procedures not followed correctly) was
-
integrationacademy.ahrq.gov/sites/default/files/2021-02/self-assessment_508_compliant.pdf
January 01, 2021 - We have processes or protocols to ensure that essential patient information is shared across the care … We have processes or protocols to coordinate referrals and information sharing with other providers … We have developed or adapted policies, processes, and procedures to ensure compliance with all
relevant … We have developed processes or protocols to check prior authorization requirements before providing … We have integrated quality improvement activities into the practice’s standard processes and
procedures
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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
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digital.ahrq.gov/ahrq-funded-projects/guidelines-decision-support-glides/annual-summary/2010
January 01, 2010 - with guideline developers to provide tools and guidance to improve guideline development and reporting processes … Pediatrics and American Academy of Otolaryngology-Head and Neck Surgery, to design, implement, and pilot processes … Among the preliminary findings, the GLIDES team discovered the importance of making sure that processes … CDS-specific processes, methods, and tools must be adaptable to an organization’s in-use system. … different approach to bridging the structured knowledge specification outputs from GEM to their own processes