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psnet.ahrq.gov/issue/cognitive-health-system
September 04, 2024 - Commentary
The cognitive health system.
Citation Text:
Coiera E. … The cognitive health system. Lancet. 2020;395(10222):463-466. doi:10.1016/s0140-6736(19)32987-3. … as symptom checkers) as well as approaches to exploit cyber-social systems within a learning health system … The cognitive health system. … September 4, 2024
Assessing the safety of a new clinical decision support system for
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psnet.ahrq.gov/issue/classification-system-incidents-and-accidents-health-care-system
September 28, 2010 - Study
Classic
A classification system for incidents and … accidents in the health-care system. … A classification for incidents and accidents in the health-care system. … A classification for incidents and accidents in the health-care system. … June 8, 2010
Review of the Australian Incident Monitoring System.
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psnet.ahrq.gov/issue/application-system-dynamics-modelling-system-safety-improvement-present-use-and-future
October 27, 2021 - Review
Emerging Classic
The application of system dynamics … modelling to system safety improvement: present use and future potential. … Citation Text:
The application of system dynamics modelling to system safety improvement: present use … This literature review examined the application of system dynamics, a simulation method that incorporates … dynamics modelling to system safety improvement: present use and future potential.
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psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system
December 04, 2019 - Multi-use Website
Canadian Anesthesia Incident Reporting System. … Citation Text:
Canadian Anesthesia Incident Reporting System. … This website provides a secure tool for submitting incident reports to a centralized system for analysis … January 4, 2024
Research from webAIRS incident reporting system. … May 4, 2015
WebAIRS Anesthesia Incident Reporting System.
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psnet.ahrq.gov/issue/national-patient-safety-alerting-system
April 15, 2020 - Government Resource
National Patient Safety Alerting System. … Citation Text:
National Patient Safety Alerting System. … National Health Service England
In response to the Francis report , this three-stage reporting system … Cite
Citation
Citation Text:
National Patient Safety Alerting System
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psnet.ahrq.gov/issue/cleveland-clinic-health-system-comprehensive-framework-health-system-patient-safety
January 04, 2017 - Commentary
Cleveland Clinic Health System: a comprehensive framework for a health … system patient safety initiative. … Citation Text:
Cleveland Clinic Health System: a comprehensive framework for a health system patient … Cite
Citation
Citation Text:
Cleveland Clinic Health System … : a comprehensive framework for a health system patient safety initiative.
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psnet.ahrq.gov/issue/learning-management-system
April 30, 2024 - Multi-use Website
Learning Management System. … Citation Text:
Learning Management System. Patient Safety Authority. … URL
Cite
Citation
Citation Text:
Learning Management System
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psnet.ahrq.gov/issue/effect-system-level-tiered-huddle-system-reporting-patient-safety-events-interrupted-time
October 07, 2020 - Study
The effect of a system-level tiered huddle system on reporting patient safety … The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted … This US health system implemented a three-level THS in hospital and ambulatory settings to increase event … The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted … July 15, 2020
Implementation of a patient safety incident management system as viewed
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system … Applying the Toyota Production System: using a patient safety alert system to reduce error. … The authors describe their institution's Patient Safety Alert system in which employees are required … Applying the Toyota Production System: using a patient safety alert system to reduce error. … June 21, 2015
Implementing a patient safety alert system.
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psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system
November 10, 2011 - Multi-use Website
WebAIRS Anesthesia Incident Reporting System. … Citation Text:
WebAIRS Anesthesia Incident Reporting System. … This website serves as a secure mechanism for submitting incident reports to a centralized system for … Cite
Citation
Citation Text:
WebAIRS Anesthesia Incident Reporting System … January 4, 2024
Research from webAIRS incident reporting system.
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psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
July 15, 2009 - Multi-use Website
Indiana Medical Error Reporting System. … Citation Text:
Indiana Medical Error Reporting System. … July 15, 2009
Indiana Medical Error Reporting System. … August 14, 2013
Indiana Medical Error Reporting System. … June 7, 2008
Patient Safety Reporting System.
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psnet.ahrq.gov/issue/mothers-face-broken-addiction-treatment-system
January 25, 2023 - Newspaper/Magazine Article
Mothers face broken addiction treatment system. … Citation Text:
Mothers face broken addiction treatment system. D'Ambrosio A. MedPage Today. … barriers mothers face trying to manage substance use disorders during pregnancy and after birth due to system … Cite
Citation
Citation Text:
Mothers face broken addiction treatment system … March 13, 2024
RaDonda Vaught says some system practices contributed to fatal mistake
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psnet.ahrq.gov/issue/implementation-integrated-computerized-prescriber-order-entry-system-chemotherapy-multisite
August 30, 2023 - Commentary
Implementation of an integrated computerized prescriber order-entry system … for chemotherapy in a multisite safety-net health system. … safety-net health system. … computerized provider order entry system. … safety-net health system.
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, … Impact of System Failures on Healthcare Workers . PSNet [internet]. … Impact of System Failures on Healthcare Workers . PSNet [internet]. … Most adverse events result from a series of circumstances in environments with underlying system flaws … Impact of System Failures on Healthcare Workers . PSNet [internet].
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psnet.ahrq.gov/issue/system-related-factors-contributing-diagnostic-errors
January 11, 2023 - Review
System-related factors contributing to diagnostic errors. … System-related factors contributing to diagnostic errors. … This review describes methods to address system and cognitive weaknesses in the diagnostic process. … System-related factors contributing to diagnostic errors. … April 7, 2021
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Related Resources
Mind the overlap: how system
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psnet.ahrq.gov/issue/implementing-clinical-occurrence-reporting-and-learning-system-double-loop-learning-incident
May 05, 2021 - Study
Implementing the clinical occurrence reporting and learning system: a double-loop … learning incident reporting system in long-term care. … system in long-term care. … Conducted in a nursing home, this study found that an existing incident reporting system redesigned to … system in long-term care.
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psnet.ahrq.gov/issue/resilient-actions-diagnostic-process-and-system-performance
November 13, 2024 - Study
Resilient actions in the diagnostic process and system performance. … Resilient actions in the diagnostic process and system performance. … In this study, primary care providers frequently relied on extraordinary actions to overcome system barriers … provides evidence that downstream measures, such as timeliness of diagnosis, may fail to detect major system … Resilient actions in the diagnostic process and system performance.
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psnet.ahrq.gov/issue/development-icu-safety-reporting-system
May 27, 2011 - Study
Development of the ICU safety reporting system. … Citation Text:
Development of the ICU safety reporting system. … Discussion includes details of the design features, a table of the system-based factors contributing … to reported incidents, and several screen shots of the reporting system itself. … The authors suggest that wide adoption of this type of reporting system, coordinated by a professional
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psnet.ahrq.gov/issue/implementation-electronic-system-medication-reconciliation
December 02, 2020 - Study
Implementation of an electronic system for medication reconciliation. … Implementation of an electronic system for medication reconciliation. … The Joint Commission has mandated that all hospitals implement a system for medication reconciliation … This study reports on the implementation of a system in which pharmacists and nurses collaborated to … Implementation of an electronic system for medication reconciliation.
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psnet.ahrq.gov/issue/medical-error-reporting-system-could-boost-patient-safety
December 14, 2022 - Newspaper/Magazine Article
Medical Error Reporting System Could Boost Patient Safety … Citation Text:
Medical Error Reporting System Could Boost Patient Safety. Ebright PR; Rapala K. … report discusses important issues for policy makers in developing a statewide incident reporting system … February 26, 2020
Adverse Health Care Events Reporting System: What Have We Learned? … June 27, 2007
Patient Safety Reporting System.