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Showing results for "system".

201. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/856584/psn-pdf
     January 01, 2024 - factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System … factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System … patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural- significant-harm Understanding the influence of human factors on team and system … Based on Human Factors Analysis and Classification System coding, decision-based errors were the most … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care

202. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60154/psn-pdf
     March 25, 2020 - Detecting patient deterioration using artificial intelligence in a rapid response system. … Detecting patient deterioration using artificial intelligence in a rapid response system. … psnet.ahrq.gov/issue/detecting-patient-deterioration-using-artificial-intelligence-rapid-response- system … This study compared an artificial intelligence (AI)-based early warning system using machine learning … //psnet.ahrq.gov/issue/detecting-patient-deterioration-using-artificial-intelligence-rapid-response-system

203. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841785/psn-pdf
     December 21, 2022 - Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety … https://psnet.ahrq.gov/issue/request-information-creating-national-healthcare-system-action-alliance- … This announcement calls for stakeholder insights on the work of the National Healthcare System Action … https://psnet.ahrq.gov/issue/request-information-creating-national-healthcare-system-action-alliance-advance-patient … https://psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety

204. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/856640/psn-pdf
     November 29, 2023 - Research from webAIRS incident reporting system. … https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system Centralized de-identified reports … https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system https://psnet.ahrq.gov/primer … /reporting-patient-safety-events https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system … https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system https://psnet.ahrq.gov/web-mm

205. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60899/psn-pdf
     September 09, 2020 - Improving transfusion safety in the operating room with a barcode scanning system designed specifically … Improving Transfusion Safety in the Operating Room With a Barcode Scanning System Designed Specifically … https://psnet.ahrq.gov/issue/improving-transfusion-safety-operating-room-barcode-scanning-system- designed-specifically … This article describes the implementation of an automated, electronic barcode scanner system to improve … Over two years, the system improved documentation compliance and averted transfusion of mismatched blood

206. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73215/psn-pdf
     May 05, 2021 - To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare … To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare … https://psnet.ahrq.gov/issue/err-system-comparison-methodologies-investigation-adverse-outcomes- healthcare … use three different methodologies – root cause analysis (RCA), human factors analysis classification system … https://psnet.ahrq.gov/issue/err-system-comparison-methodologies-investigation-adverse-outcomes-healthcare

207. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50872/psn-pdf
     February 05, 2020 - An improved patient safety reporting system increases reports of disruptive behavior in the perioperative … An improved patient safety reporting system increases reports of disruptive behavior in the perioperative … https://psnet.ahrq.gov/issue/improved-patient-safety-reporting-system-increases-reports-disruptive- … behavior-perioperative This study describes the impact of an upgraded patient safety reporting system … The upgraded system resulted in a significant increase in the quantity and length of event reporting

208. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836822/psn-pdf
     March 30, 2022 - Leveraging a safety event management system to improve organizational learning and safety culture. … Leveraging a safety event management system to improve organizational learning and safety culture. … https://psnet.ahrq.gov/issue/leveraging-safety-event-management-system-improve-organizational-learning … This pediatric health system implemented a new safety event management system (SEMS) aimed at increased … https://psnet.ahrq.gov/issue/leveraging-safety-event-management-system-improve-organizational-learning-and-safety-culture

209. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47996/psn-pdf
     January 01, 2021 - Building an ambulatory safety program at an academic health system. … Building an Ambulatory Safety Program at an Academic Health System. … https://psnet.ahrq.gov/issue/building-ambulatory-safety-program-academic-health-system Outpatient safety … This project report describes an ambulatory safety program at an academic health system that targeted … Decentralizing reporting response responsibilities throughout the system significantly increased feedback

210. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841768/psn-pdf
     December 21, 2022 - Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed … Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed … https://psnet.ahrq.gov/issue/implementation-online-reporting-system-identify-unprofessional-behaviors-and … Findings suggest that awareness and support for the online incident reporting system among trainees … https://psnet.ahrq.gov/issue/implementation-online-reporting-system-identify-unprofessional-behaviors-and-mistreatment

211. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72720/psn-pdf
     February 10, 2021 - Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities … Health System Leaders’ Role in Addressing Racism: Time to Prioritize Eliminating Health Care Disparities … https://psnet.ahrq.gov/issue/health-system-leaders-role-addressing-racism-time-prioritize-eliminating … This commentary outlines the key steps health system leaders could take to identify and eliminate health … recognizing and addressing the systems failures contributing to disparities, a commitment from health system

212. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854986/psn-pdf
     November 01, 2023 - Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated … Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated … https://psnet.ahrq.gov/issue/implementing-safer-and-more-reliable-system-monitor-test-results-teaching … - university Laboratory tests are an integral part of diagnosing illness and injury, but system issues … https://psnet.ahrq.gov/issue/implementing-safer-and-more-reliable-system-monitor-test-results-teaching-university

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/842416/psn-pdf
     January 11, 2023 - A failure in the medication delivery system-how disclosure and systems investigation improve patient … A failure in the medication delivery system—how disclosure and systems investigation improve patient … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation … This commentary describes one health system’s effort to identify and improve the system factors (systems … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient

214. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50895/psn-pdf
     February 12, 2020 - Nurses as a source of system-level resilience: Secondary analysis of qualitative data from a study of … Nurses as a source of system-level resilience: Secondary analysis of qualitative data from a study of … https://psnet.ahrq.gov/issue/nurses-source-system-level-resilience-secondary-analysis-qualitative-data … This study explored the ways nurses contribute to system-level resilience in relation to infusion safety … intravenous infusion administration in 16 English hospitals suggest that nurses are a key source of system-level

215. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60707/psn-pdf
     July 22, 2020 - The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes … The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes … https://psnet.ahrq.gov/issue/devil-detail-how-closed-loop-documentation-system-iv-infusion-administration … conducted a sociotechnical investigation to describe the implementation of a closed-loop documentation system … In this case, the smart pumps were ‘mapped’ to an electronic prescribing and administration system.

216. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61067/psn-pdf
     January 01, 2021 - A program to provide clinicians with feedback on their diagnostic performance in a learning health system … A program to provide clinicians with feedback on their diagnostic performance in a learning health system … psnet.ahrq.gov/issue/program-provide-clinicians-feedback-their-diagnostic-performance-learning- health-system … This article describes the development of a learning health system around diagnostic safety at one large … , integrated health care system.

217. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/842772/psn-pdf
     January 18, 2023 - Short- and long-term effects of an electronic medication management system on paediatric prescribing … Short- and long-term effects of an electronic medication management system on paediatric prescribing … https://psnet.ahrq.gov/issue/short-and-long-term-effects-electronic-medication-management-system- paediatric-prescribing … controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system … /psnet.ahrq.gov/issue/reported-medication-errors-after-introducing-electronic-medication-management-system

218. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73246/psn-pdf
     May 12, 2021 - Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health … Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health … https://psnet.ahrq.gov/issue/self-reported-learning-srl-voluntary-incident-reporting-system-experience … Three hospitals in one health system implemented a voluntary error reporting system for clinicians to … https://psnet.ahrq.gov/issue/self-reported-learning-srl-voluntary-incident-reporting-system-experience-within-large-health

219. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50751/psn-pdf
     December 18, 2019 - Using a machine learning system to identify and prevent medication prescribing errors: a clinical and … Using a machine learning system to identify and prevent medication prescribing errors: A clinical and … https://psnet.ahrq.gov/issue/using-machine-learning-system-identify-and-prevent-medication-prescribing … This retrospective study evaluates the clinical validity and value of using a machine learning system … (MedAware) for CDS as compared to an existing CDS system.

220. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60550/psn-pdf
     June 03, 2020 - Clinical efficacy of combined surgical patient safety system and the World Health Organization's checklists … Clinical Efficacy of Combined Surgical Patient Safety System and the World Health Organization’s Checklists … https://psnet.ahrq.gov/issue/clinical-efficacy-combined-surgical-patient-safety-system-and-world-health … surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System … https://psnet.ahrq.gov/issue/development-and-validation-surgical-patient-safety-system-surpass-checklist