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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
November 30, 2010 - One randomized
controlled trial found that comprehensive chart review by a consultant pharmacist with … Study entry criteria were determined based on elements from a literature review (indicating
patient … The final protocol
was approved by the
institutional review boards
at participating health care
systems … Improving
prescribing patterns for the elderly through an online
drug utilization review intervention … Older adults in the
emergency department: A systematic review of
patterns of use, adverse outcomes,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
March 21, 2008 - None of these errors would have been detected by chart review alone. … Conclusion:
Self-reporting followed by chart review is feasible in primary care practices and discovers … When post-visit
interviews with patients who received prescriptions are combined with chart review data … The chart review
identified 66 additional errors, mostly documentation errors; 16 of the errors (19.1 … Methods to expand the time slot—such as a retrospective review of
transactions prior to the point of
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gururaja_7.pdf
January 24, 2008 - Review of Relevant Literature
Learning in simulated environments should be self-directed, and participants … Prior to implementation, we obtained institutional review board (IRB) approval at an exempt
status as … Using the results of our literature review, the assessment instrument included items that
represented … An
iterative process of review and refinement was used to finalize the instrument. … Literature review. AHRQ Publication No. 05-
0053.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nishisaki_44.pdf
April 19, 2008 - This study was approved by the Institutional Review Board of the Children’s Hospital of
Philadelphia … Effectiveness of
retraining after basic cardiopulmonary resuscitation
courses: A literature review. … Accuracy
of physician self-assessment compared with observed
measures of competence: A systematic review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
April 07, 2008 - In the future, we expect that advances in computing power will lead to a routine interactive
review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
March 27, 2008 - conditions—where a massive amount of data is theoretically available but pragmatically
impossible to review—the … evolving unsafe conditions or plans.33, 34 Signovers appear to provide a
medium for “fresh eyes” to review … that enhanced
co-orientation in this these settings included providing time for the incoming staff to review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
May 05, 2008 - history and, as a result, utilize this handoff
process as a key source of information; (3) time to review … Approval by the Institutional Review Board at the Duke University School of Medicine was
obtained prior … For example, the patient’s primary nurse had
to first review all currently infusing intravenous medications
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Devine_83.pdf
April 06, 2008 - Introduction
A recent systematic review of the impact of health information technology (HIT) on the … A review of the necessary components was
undertaken prior to transitioning to e-prescribing. … Systematic review:
Impact of health information technology on quality,
efficiency and costs of medical … Evaluation of
outpatient computerized physician order entry
systems: A systematic review. … Medication-
related clinical decision support in computerized
provider order entry systems: A review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - In emergent situations, facilities can approve nursing retrieval of
medications prior to pharmacy review … However, retrieving
medications by the override mechanism and administering prior to pharmacy review … In addition to these “five patient rights,” the system allows
for review of lab values and for allergy … Administering medications prior to a pharmacist review increases the risk of medication
errors.3-5 The … Joint Commission Standard Medication Management 4.10 (MM.4.10) states that a
pharmacist must review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
May 06, 2008 - Protection
As PEERs was developed, Trinity Health worked to maintain the peer review protection afforded … This tool allows the coordinator to assign the report to others involved in the peer review process … Upon review of each report,
the risk manager/PEERs coordinator assigns it a severity index. … A review of PEERs reports revealed that approximately 25 percent of all events could be
attributed to … This will allow us to review
incidents by clinical condition and to pull in full patient demographic
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
January 01, 2007 - 2
We conducted a structured literature review using PubMed to identify appropriate denominators
for … The literature review covered English language articles published between 1995 and 2004 that
addressed … Results
Literature Review
Broad search terms such as “Benchmarking[MESH] AND Hospitals/standards[MESH … Using a cross-sectional chart
review, Michel and colleagues found 9.8 to 15.4 percent of charts with … Schade, MLS,
who performed the literature searches for the systematic review.
11
Supplementary
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
March 10, 2008 - available and relatively
inexpensive to use.6 The AHRQ PSIs were developed through a literature search, review … All codes were described
using their titles as listed in the ICD-10-
Step 2: Panel Review and Assessment … Regarding postoperative hip fracture (PSI 8), based on Canadian chart review experience, it was
suggested … ICD-10-WHO diagnosis coding algorithms for defining 15 AHRQ PSIs through
an explicit and diligent review … validation pilot project is now
underway to assess the validity of 10 PSIs through detailed chart review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-SinghG_67.pdf
April 14, 2008 - A
literature review informed the development of the cybernetic model. … The study protocol was approved by the Social and Behavioral Sciences Institutional Review
Board of … The nature of safety culture: A
review of theory and research. … Assessing
patient safety culture: A review and synthesis of the
measurement tool. … Measuring
patient safety climate: A review of surveys.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ehringer_17.pdf
February 08, 2008 - • Date of latest review.
7
• Facility name.
• Allergies or adverse reactions. … best practice” (CBP) committee meets for 1 hour monthly to determine and develop
order criteria and review … Evaluation of
outpatient computerized physician medication order
entry systems: A systematic review … Look-alike, sound-alike drugs review:
Include look-alike packaging as an additional safety
check. … 17
Appendix
Creating Preprinted Physician Orders for Clinical “best
practice” Review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Emanuel_19.pdf
February 20, 2008 - A review of 50
randomized controlled trials. JAMA 1992; 268:
1111-1117.
11. … Effectiveness of teaching quality improvement to
clinicians: A systematic review. … Evaluation criteria in studies of continuing
education in the health professions: A critical review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Singh-R_68.pdf
April 20, 2008 - Accurate collection, review, and documentation of history, physical exam,
laboratory results, medications … Review and learn. Systemic learning from process evaluation (without assigning blame). … The micromodel and the lists of failure modes were
developed by review of the literature and consultation … Each meeting was conducted using the
following structure:
• Brief review of the orientation material … A literature review exploring how
healthcare professionals contribute to the assessment
and control
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
January 01, 2007 - Reviewers filled out a peer review sheet to indicate their opinion as to
whether standard of care had … After each incident had been analyzed and peer review completed, the QI director assigned a
primary … Each unit or division made local modifications to the
reporting format and initial review process to … When a case was closed, it was cross-referenced in the peer review database of involved
providers. … Additional
physician and staff time are needed for coordination and department-level review.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
March 27, 2008 - .15
In January 2006, after a serious wrong-side surgery event at a New York hospital in 2005 and a
review … The expert committee assembled to review the data derived from the RCAs, identified
commonalities in … After review by the Department of Health and approval by
the Commissioner of Health, the protocol was … One study estimated that 1,200 to 2,700 events
occur annually in the United States.20 Based on a review … A follow-up review of
wrong site surgery; Oakbrook Terrace, IL: The Joint
Commission; 2001 Dec 5.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Kind_31.pdf
March 31, 2008 - The Institutional Review Board at the
University of Wisconsin approved this study. … A recent
systematic review noted that studies that have examined recommended discharge summary
components … relatively
high rates of omission.1, 2, 19 However, the vast majority of studies referenced in this review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Goeschel_24.pdf
January 01, 2008 - an
aggregated score of the other ICU teams in Michigan and were asked to meet with their CEOs to
review