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Total Results: 399 records

Showing results for "safer iii critical".

161. Infused, Not Ingested | PSNet
     psnet.ahrq.gov/web-mm/infused-not-ingested
     February 01, 2017 - Since critical care units have an entirely different level of acuity, their practice competencies are … in critical care—floated to a unit where he lacked necessary competencies. … using a root cause analysis (RCA), (ii) disclosure to the patient and family with an apology, and (iii … That he did not object to a critical care assignment or seek support should raise questions regarding … To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

162. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854897/psn-pdf
     October 31, 2023 - Reason highlights two critical aspects of these holes. … desensitized to frequent warnings, leading to reflexive dismissal and the possibility of overlooking critical … In pediatric care, accurate assessment of a child’s weight and growth trajectory is critical for determining … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices.

163. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet
     psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
     March 15, 2023 - Reason highlights two critical aspects of these holes. … desensitized to frequent warnings, leading to reflexive dismissal and the possibility of overlooking critical … In pediatric care, accurate assessment of a child’s weight and growth trajectory is critical for determining … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices .

164. Improving Safety and Quality with Integrated Technology (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r01hs015321-guise-final-report-2009.pdf
     January 01, 2009 - Demonstrated the value of an outpatient alert system to increase GBS screening III. … In general, there was improvement in timely access to time critical information, and decision support … experience of the patient rather than distinct inpatient and outpatient silos, can we provide better and safer … Decline in unknown GBS status III. … To err is human: building a safer health system.

165. Medical Team Training Programs in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Baker.pdf
     February 01, 2005 - In the Agency for Healthcare Research and Quality (AHRQ) Evidence Report, Making Health Care Safer: … makes provisions for follow-up skills practice (i.e., Phase II) and recurrency training (i.e., Phase III … ACRM in anesthesiology and recently proliferated with the publication of To Err Is Human: Building a Safer … In: Making health care safer: A critical analysis of patient safety practices. … To err is human: building a safer health system.

166. Making Healthcare Safer IV_Rapid Response: Use of Report Cards and Outcome Measurements To Improve the Safety of Surgical Care (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-rapid-response-surgical-report-cards.pdf
     November 01, 2023 - • Few studies addressed the critical aspects of surgical report cards such as implementation of outcomes-based … Appendix C contains the data tables as well as the critical appraisal tables. Figure 1. … Lastly, we found few studies that addressed the critical aspects of surgical report cards such as implementation … Postoperative Complications: Looking Forward to a Safer Future. … A Statewide Collaboration: Ohio Level III Trauma Centers' Approach to the Development of a Benchmarking

167. Making Healthcare Safer IV Rapid Review: Examining the Impact of Implementing High-Reliability Organization Principles on Patient Safety Outcomes (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/hro-rapid-research.pdf
     May 01, 2025 - conditions before adverse events can occur.6 Respectful interaction and heedful interrelating are critical … However, MHS III described additional HRO characteristics such as: having strong leaders who are committed … or not, leader presence through effective leadership rounding at all levels of the organization is critical … Making Healthcare Safer IV. … https://www.ahrq.gov/research/findings/mak ing-healthcare-safer/index.html.

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837791/psn-pdf
     August 05, 2022 - events in ambulatory and long term care settings.12 One recent funding opportunity, Making Health Care Safer … Making healthcare safer III: a critical analysis of existing and emerging patient safety practices.

169. Patient Safety in the Ambulatory Care Setting | PSNet
     psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
     April 27, 2022 - in ambulatory and long term care settings. 12 One recent funding opportunity, Making Health Care Safer … Making healthcare safer III: a critical analysis of existing and emerging patient safety practices .

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49475/psn-pdf
     March 01, 2005 - : the failures are (i) less frequent but more consequential, (ii) more challenging to detect, and (iii … Equally important is the apparently casual way in which a critical diagnosis was discarded. … We can only speculate because the details are unavailable, but the critical issue is that the neurosurgeon … The Federal government insists that adding IT to hospitals will make patients safer.(3) Surprisingly … Cook, MD Associate Professor, Department of Anesthesia and Critical Care Director, Cognitive Technologies

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49723/psn-pdf
     January 01, 2015 - increasing the number of displays that need to be monitored on overall vigilance and detection of critical … The participants detected fewer critical signals as the number of tracings to be monitored increased … solutions include: (i) additional training, (ii) having more than one person monitor the displays, and (iii … Ongoing review of near-misses and poor outcomes is also an essential step towards building a safer system … Time and number of displays impact critical signal detection in fetal heart rate tracings.

172. Good Catch in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/good-catch-operating-room
     August 27, 2017 - decrease in surgical morbidity and annual mortality; (ii) a reduction in hospital-acquired conditions; (iii … Critical role of the surgeon–anesthesiologist relationship for patient safety. … Medical team training improves team performance: AOA critical issues. … Safer paediatric surgical teams: a 5-year evaluation of crew resource management implementation and outcomes … Such understanding is conveyed by repeating critical parts of the message.

173. Resource List - AHRQ Ambulatory Surgery Center Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
     April 01, 2023 - mailto:SafetyCultureSurveys@westat.com SOPS Ambulatory Surgery Center Survey Resource List 2 III … “SBAR Report to Physician About a Critical Situation” is a worksheet/script that a provider can use … /Shining-a-Light-Safer-Health-Care-Through- Transparency.aspx (requires free account setup and login) … How To Use This Resource List III. Contents IV. … Shining a Light: Safer Health Care Through Transparency 15.

174. AHRQ Grant Final Progress Report: Real-Time, Wireless, Networked Feedback for Bed-Tilt Compliance (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/thomas1-report.pdf
     January 01, 2024 - We also hope this will constitute a critical step toward reducing the amount of time patients spend … DL, Sherner III JH, Fitzpatrick TM, et al. … Critical care clinicians’ knowledge of evidence- based guidelines for preventing ventilator-associated … Critical care nurses’ knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia … To err is human: Building a safer health system.

175. Double Trouble | PSNet
     psnet.ahrq.gov/web-mm/double-trouble
     August 01, 2012 - Starting therapy in an elderly patient with a single agent is generally a safer strategy, and many patients … the geriatric patient, (ii) the importance of anticipating confusion from sound-alike medications, (iii … .( 10 ) Explaining that some pills contain multiple pharmacotherapeutic agents must be considered a critical … To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 3.

176. Chest Tube Complications | PSNet
     psnet.ahrq.gov/web-mm/chest-tube-complications
     September 27, 2023 - However, some experts argue that a safer approach is to clamp the chest tube and monitor closely for … Lekshmi Santhosh, MD Clinical Fellow Division of Pulmonary and Critical Care Medicine Department of … Courtney Broaddus, MD Professor Division of Pulmonary and Critical Care Medicine Department of Medicine … Millikan JS, Moore EE, Steiner E, Aragon GE, Van Way CW III.

177. Time of Death? | PSNet
     psnet.ahrq.gov/web-mm/time-death
     January 03, 2017 - skills, including (i) high prevalence of untrained providers, (ii) overly complex treatment algorithms, (iii … team performance, including (i) problems of situation awareness, (ii) lack of team assertiveness, (iii … assertiveness are essential for effective team performance in health care and are especially relevant in critical … Discrepant attitudes about teamwork among critical care nurses and physicians. … November 18, 2016 Can we make postoperative patient handovers safer?

178. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - Student Riley Graham Medical Student Perrin Griffin Medical Student Johns Hopkins James Abernathy, III … For example, although barcode scanning might lead to safer intravenous drug administration, it can increase … (iii) allow you to adapt and reconfigure your workspace to your needs? … Abernathy III. (2023) Creation of a SEIPS 101 Tasks and Tools Matrix on Anesthesia Medication Delivery … Abernathy III, K. Catchpole, C. Lusk, J.

179. Cognitive Engineering for Complex Decision Making & Problem Solving in Acute Care - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r01hs022542-hettinger-final-report-2020.pdf
     January 01, 2020 - Section III: Methods Due to the long nature of this study and multiple components, the report has been … Current EHRs typically store information in silos, often displaying critical information in different … This work includes the development of 11 concept maps to highlight the critical communication needs … can improve quality in healthcare and stakeholders have agreed that health IT systems are key to safer … Objectives of the study Section II: Scope Background Context Settings Participants Section III

180. Techno Trip | PSNet
     psnet.ahrq.gov/web-mm/techno-trip
     May 01, 2005 - ): the failures are (i) less frequent but more consequential, (ii) more challenging to detect, and (iii … Equally important is the apparently casual way in which a critical diagnosis was discarded. … We can only speculate because the details are unavailable, but the critical issue is that the neurosurgeon … The Federal government insists that adding IT to hospitals will make patients safer.( 3 ) Surprisingly … Cook, MD Associate Professor, Department of Anesthesia and Critical Care Director, Cognitive Technologies