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psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
July 05, 2008 - He goes on to share his personal experience with the health care system in describing the details of … They include greater access for patients to the system, improved application of science at the bedside … , and better attention to the interactions between patients and the system. … Health System. … system patient safety initiative.
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psnet.ahrq.gov/issue/cultural-and-associated-enablers-and-barriers-adverse-incident-reporting
March 23, 2011 - Learning from disasters to improve patient safety: applying the generic disaster pathway to health system … June 29, 2011
Implementation of a patient safety incident management system as viewed … June 14, 2011
'Between the flags': implementing a rapid response system at scale. … August 12, 2014
Investigating patient safety culture across a health system: multilevel … February 25, 2015
Managing clinical failure: a complex adaptive system perspective.
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psnet.ahrq.gov/issue/learning-incident-reporting-analysis-incidents-resulting-patient-injuries-web-based-system
August 04, 2021 - Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System … March 25, 2020
Root cause analysis using the prevention and recovery information system
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psnet.ahrq.gov/issue/nature-severity-and-causes-medication-incidents-australian-community-pharmacy-incident
May 05, 2021 - severity and causes of medication incidents from an Australian community pharmacy incident reporting system … severity and causes of medication incidents from an Australian community pharmacy incident reporting system … severity and causes of medication incidents from an Australian community pharmacy incident reporting system … April 16, 2018
Implementing the clinical occurrence reporting and learning system: a … double-loop learning incident reporting system in long-term care.
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system … The results of the review and suggested system improvement opportunities are then presented to subject … The updated system found eight patients with an ectopic pregnancy with possible early delays in care … which were flagged in the SureNet system that led to clear communication with the involved clinicians … There must be funding to implement actionable results in the system.
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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - teams exist (see Table 1), and a 2006 consensus conference advocated use of the term "rapid response system … Rapid Response System Models Model Personnel Duties Medical Emergency Team Physicians (critical care … Typical Rapid Response System Calling Criteria Any staff member may call the team if one of the following … July 18, 2024
Understanding the enablers and barriers to implementing a patient-led escalation system … 2024
Opinions of nurses and physicians on a patient, family and visitor activated rapid response system
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psnet.ahrq.gov/issue/best-care-lower-cost-path-continuously-learning-health-care-america
July 08, 2016 - Committee on the Learning Health Care System in America, Institute of Medicine. … Committee on the Learning Health Care System in America, Institute of Medicine. … Committee on the Learning Health Care System in America, Institute of Medicine. … July 8, 2016
Engineering a Learning Healthcare System: A Look at the Future: Workshop … July 27, 2011
To Err Is Human: Building a Safer Health System.
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psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future
February 24, 2016 - Newspaper/Magazine Article
Is an indication-based prescribing system in our future … Citation Text:
Is an indication-based prescribing system in our future? … Cite
Citation
Citation Text:
Is an indication-based prescribing system … March 9, 2016
Hardwiring safety into the computer system: one hospital's actions to provide … 2017
Electronic approaches to making sense of the text in the adverse event reporting system
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psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
February 24, 2011 - Commentary
Creating a safer health care system: finding the constraint. … Creating a safer health care system: finding the constraint. JAMA. 2005;294(22):2906-8. … Creating a safer health care system: finding the constraint. JAMA. 2005;294(22):2906-8. … 2008
Perspective
What Can the Rest of the Health Care System
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psnet.ahrq.gov/issue/errors-originating-hospital-and-health-system-outpatient-pharmacies
December 19, 2016 - Newspaper/Magazine Article
Errors originating in hospital and health-system outpatient … Citation Text:
Errors originating in hospital and health-system outpatient pharmacies. … Cite
Citation
Citation Text:
Errors originating in hospital and health-system
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psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospital-comparison
January 15, 2009 - Study
The medical emergency team system: a two hospital comparison. … The Medical Emergency Team system: a two hospital comparison. … The Medical Emergency Team system: a two hospital comparison. … January 4, 2012
Enabling a learning healthcare system with automated computer protocols … January 15, 2009
The medical emergency team system and not-for-resuscitation orders:
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psnet.ahrq.gov/issue/nurse-driven-system-improving-patient-quality-outcomes
October 12, 2011 - Commentary
A nurse-driven system for improving patient quality outcomes. … A nurse-driven system for improving patient quality outcomes. … A nurse-driven system for improving patient quality outcomes. … June 23, 2009
Mature rapid response system and potentially avoidable cardiopulmonary
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psnet.ahrq.gov/issue/promoting-patient-safety-using-early-warning-scoring-system
October 16, 2012 - Study
Promoting patient safety using an early warning scoring system. … Promoting patient safety using an early warning scoring system. Nurs Stand. 2008;22(44):35-40. … Promoting patient safety using an early warning scoring system. Nurs Stand. 2008;22(44):35-40. … May 3, 2023
Longitudinal evaluation of a pediatric rapid response system with realist … rapid response system.
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psnet.ahrq.gov/issue/optimizing-patient-safety-through-system-strategies-and-patient-engagement
June 22, 2016 - Newspaper/Magazine Article
Optimizing patient safety through system strategies and … Citation Text:
Optimizing patient safety through system strategies and patient engagement. … Cite
Citation
Citation Text:
Optimizing patient safety through system … October 28, 2015
A system-based approach to managing patient safety in ambulatory care
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psnet.ahrq.gov/issue/safety-electronic-prescribing-manifestations-mechanisms-and-rates-system-related-errors
February 15, 2012 - The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related … The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors … The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors … August 26, 2020
Failure to utilize functions of an electronic prescribing system and … September 24, 2016
Failure to utilize functions of an electronic prescribing system and
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psnet.ahrq.gov/issue/development-expert-system-classification-medical-errors
June 22, 2009 - Commentary
Development of an expert system for classification of medical errors. … Development of an expert system for classification of medical errors. … Development of an expert system for classification of medical errors. … June 23, 2021
Enabling a learning healthcare system with automated computer protocols
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psnet.ahrq.gov/issue/diagnostic-accuracy-gps-when-using-early-intervention-decision-support-system-high-fidelity
April 03, 2018 - Study
Diagnostic accuracy of GPs when using an early-intervention decision support system … Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity … Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity … August 29, 2018
The impact of a diagnostic decision support system on the consultation … June 21, 2017
A learning health care system using computer-aided diagnosis.
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psnet.ahrq.gov/curated-library/rapid-response-systems
September 15, 2024 - 1)
INNOVATION
Advance Alert Monitor Program: An Automated Early Warning System … Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical
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psnet.ahrq.gov/issue/using-bar-coded-medication-administration-system-prevent-medication-errors-community-hospital
October 01, 2008 - Study
Using a bar-coded medication administration system to prevent medication errors … Using a bar-coded medication administration system to prevent medication errors in a community hospital … American Journal of Health-System Pharmacy. 2005;62(24). doi:10.2146/ajhp050138. … American Journal of Health-System Pharmacy . 2005; 62 (24) . … American Journal of Health-System Pharmacy. 2005;62(24). doi:10.2146/ajhp050138.
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psnet.ahrq.gov/issue/implementation-patient-safety-incident-management-system-viewed-doctors-nurses-and-allied
March 23, 2011 - Study
Implementation of a patient safety incident management system as viewed by … Implementation of a patient safety incident management system as viewed by doctors, nurses and allied … Implementation of a patient safety incident management system as viewed by doctors, nurses and allied … June 14, 2011
Investigating patient safety culture across a health system: multilevel … May 3, 2023
The effect of a system-level tiered huddle system on reporting patient safety