-
psnet.ahrq.gov/node/41423/psn-pdf
January 03, 2017 - advocates for a highly structured electronic health record with real-time alerts and designated
team responsibility
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psnet.ahrq.gov/node/48187/psn-pdf
August 21, 2019 - The authors conclude that using a
learning culture perspective that acknowledges blame and responsibility
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psnet.ahrq.gov/node/60204/psn-pdf
April 08, 2020 - Respondents cited moral and social responsibility as
being the strongest driver to continue working
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/appa.html
October 01, 2015 - Handoff: The transfer of information (along with authority and responsibility) during transitions in
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psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - severity of adverse events and patients' experience, and also the effect on caregivers.( 2 ) Taking responsibility … Modern approaches to understanding the system causes of error tend to reduce individual responsibility … This can be problematic if it is unclear whose responsibility it is to address complex system issues. … some extent.( 14,15 )
Professionals' training and socialization instill a high sense of individual responsibility
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - system-based changes severely limit resident decision making, new physicians may not learn to accept ultimate responsibility … That way, the learners feel complete personal responsibility for their patients. … they are beyond their area of competence while preserving the intense personal sense of commitment and responsibility … supervision (ie, through computerized order entry), it will be vital to retain trainees’ personal sense of responsibility
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Change Needed/
Quality Improvement Approach
19
20
Systems Change Needed (1)
• When there is shared responsibility … , need to clearly define
what team has the primary responsibility for a patient
• In this case, it … was unclear whether an Internal Medicine or
Orthopedics team held primary responsibility
• Need to
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2024-sops-deidentified-data-release-agreement.pdf
January 01, 2024 - ,
releasing or disclosing the Data set(s) or any part to others in my organization, I retain full
responsibility … I understand that this DRA is required by AHRQ to ensure responsibility for compliance with this
DRA
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Disclosure (2)
Apologize – say you are sorry in a sincere manner early in the conversation
Explain responsibility … www.ncbi.nlm.nih.gov/pubmed/20628132
*
Disclosure as a Team
Disclosure has traditionally been viewed as responsibility … delivered by numerous providers, sometimes across institutions
Error disclosure is best viewed as the responsibility
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psnet.ahrq.gov/node/43909/psn-pdf
March 11, 2015 - The authors discuss the importance of leadership in incentivizing CPOE use and vendor responsibility
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psnet.ahrq.gov/node/44345/psn-pdf
October 05, 2015 - Although apologies that focused on admissions of responsibility, expressions of regret, and offers of
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psnet.ahrq.gov/node/46087/psn-pdf
September 24, 2017 - who-responsible-safe-introduction-new-surgical-technology-important-legal-
precedent-da-vinci
This commentary explores the responsibility
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psnet.ahrq.gov/node/37294/psn-pdf
May 21, 2013 - https://psnet.ahrq.gov/issue/improving-hand-communication
The process of transferring primary responsibility
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psnet.ahrq.gov/node/47287/psn-pdf
December 19, 2018 - Clinicians reported a balance between accepting
personal responsibility and identifying systems-level
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digital.ahrq.gov/health-it-tools-and-resources/implementation-toolsets-e-prescribing/toolset-e-prescribing/tool-11-e-prescribing-team-roster-e-prescribing-implementation-toolset
January 01, 2023 - E-Prescribing or EHR Implementation Leader
Role: Has overall responsibility for the e-prescribing … project timeline
Identifies tasks and available resources to do the work for each task
Assigns responsibility
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/engaging-srexec-slides.pptx
January 01, 2017 - Clear goals, timelines, and mission
Necessary structure in place–people, roles, authority, and responsibility … unique, even uncomfortable
Requires less prescriptive approach
Requires team members at all levels of responsibility
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www.ahrq.gov/talkingquality/plan/role.html
November 01, 2018 - Do It All Yourself
Some sponsors want to take complete responsibility for producing quality scores,
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psnet.ahrq.gov/issue/hospital-trustees-shift-their-focus-medical-safety
July 30, 2014 - This article discusses board members' responsibility to understand patient safety issues at the hospitals
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psnet.ahrq.gov/issue/incentives-patient-safety-holding-healthcare-executives-accountable
June 29, 2005 - This commentary discusses health care executive responsibility for safety and quality improvement.
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psnet.ahrq.gov/node/46995/psn-pdf
January 01, 2021 - reports into 4 professionalism domains: competent
medical care, clear and respectful communication, responsibility