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Showing results for "system".

381. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43843/psn-pdf
     February 11, 2015 - Impact of a clinical decision support system for high-alert medications on the prevention of prescription … Impact of a clinical decision support system for high-alert medications on the prevention of prescription … https://psnet.ahrq.gov/issue/impact-clinical-decision-support-system-high-alert-medications-prevention … patterns emerged following the alerts, but the authors did not identify patient harm associated with the system … https://psnet.ahrq.gov/issue/impact-clinical-decision-support-system-high-alert-medications-prevention-prescription-errors

382. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46815/psn-pdf
     April 29, 2018 - Designing and evaluating an automated system for real- time medication administration error detection … Designing and evaluating an automated system for real-time medication administration error detection … https://psnet.ahrq.gov/issue/designing-and-evaluating-automated-system-real-time-medication- administration-error-detection … In this prospective study, investigators found that implementation of an automated system for detecting … https://psnet.ahrq.gov/issue/designing-and-evaluating-automated-system-real-time-medication-administration-error-detection

383. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
     February 01, 2014 - systems approach to error analysis Identify weaknesses or failures in key elements of the medication-use system … When the physician searched for liquid oxycodone in the computerized prescriber order entry (CPOE) system … At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry … failures The Institute for Safe Medication Practices (ISMP) has identified 10 key system elements that … Analysis (3) Communication of Drug Information The list of choices for oxycodone in the CPOE system

384. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49699/psn-pdf
     February 01, 2014 - https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based … Identify weaknesses or failures in key elements of the medication use system. … At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one … system failures that are amenable to correction. … Elements of the Medication-Use System that is used here, should be employed.

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37912/psn-pdf
     September 25, 2008 - Association of a clinical knowledge support system with improved patient safety, reduced complications … Association of a clinical knowledge support system with improved patient safety, reduced complications … https://psnet.ahrq.gov/issue/association-clinical-knowledge-support-system-improved-patient-safety- … reduced-complications This study discovered that hospitals providing access to a popular clinical knowledge support system … https://psnet.ahrq.gov/issue/association-clinical-knowledge-support-system-improved-patient-safety-reduced-complications

386. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47455/psn-pdf
     October 31, 2018 - Assessment of opioid prescribing practices before and after implementation of a health system intervention … Assessment of Opioid Prescribing Practices Before and After Implementation of a Health System Intervention … https://psnet.ahrq.gov/issue/assessment-opioid-prescribing-practices-and-after-implementation-health- system-intervention … This multimodal, health care system- level intervention to reduce opioid overprescribing consisted of … https://psnet.ahrq.gov/issue/assessment-opioid-prescribing-practices-and-after-implementation-health-system-intervention

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44075/psn-pdf
     July 16, 2015 - Physicians failed to write flawless prescriptions when computerized physician order entry system crashed … Physicians Failed to Write Flawless Prescriptions When Computerized Physician Order Entry System Crashed … psnet.ahrq.gov/issue/physicians-failed-write-flawless-prescriptions-when-computerized-physician- order-entry-system … In this case study, system failures resulted in physicians reverting to handwritten medication orders … psnet.ahrq.gov/issue/physicians-failed-write-flawless-prescriptions-when-computerized-physician-order-entry-system

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35639/psn-pdf
     May 27, 2011 - Clinical application of a computerized system for physician order entry with clinical decision support … Clinical application of a computerized system for physician order entry with clinical decision support … https://psnet.ahrq.gov/issue/clinical-application-computerized-system-physician-order-entry-clinical- … events that led to an error in a long-term care setting might have been avoided with a computerized system … https://psnet.ahrq.gov/issue/clinical-application-computerized-system-physician-order-entry-clinical-decision-support

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45505/psn-pdf
     July 01, 2017 - A model for the departmental quality management infrastructure within an academic health system. … A Model for the Departmental Quality Management Infrastructure Within an Academic Health System. … /psnet.ahrq.gov/issue/model-departmental-quality-management-infrastructure-within-academic- health-system … ://psnet.ahrq.gov/issue/model-departmental-quality-management-infrastructure-within-academic-health-system … ://psnet.ahrq.gov/issue/model-departmental-quality-management-infrastructure-within-academic-health-system

390. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47607/psn-pdf
     February 13, 2019 - Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach … Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach … https://psnet.ahrq.gov/issue/infection-prevention-long-term-care-re-evaluating-system-using-human-factors … https://psnet.ahrq.gov/issue/infection-prevention-long-term-care-re-evaluating-system-using-human-factors-engineering … https://psnet.ahrq.gov/issue/infection-prevention-long-term-care-re-evaluating-system-using-human-factors-engineering

391. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37113/psn-pdf
     March 24, 2011 - Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. … Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. … https://psnet.ahrq.gov/issue/mature-rapid-response-system-and-potentially-avoidable-cardiopulmonary- … arrests-hospital Implementation of a rapid response system (RRS, also known as medical emergency team … https://psnet.ahrq.gov/issue/mature-rapid-response-system-and-potentially-avoidable-cardiopulmonary-arrests-hospital

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45268/psn-pdf
     September 27, 2016 - The role of radio frequency detection system embedded surgical sponges in preventing retained surgical … The Role of Radio Frequency Detection System Embedded Surgical Sponges in Preventing Retained Surgical … https://psnet.ahrq.gov/issue/role-radio-frequency-detection-system-embedded-surgical-sponges- preventing-retained-surgical … The RFD system identified sponges that would not have been detected, either because the sponge and … https://psnet.ahrq.gov/issue/role-radio-frequency-detection-system-embedded-surgical-sponges-preventing-retained-surgical

393. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44215/psn-pdf
     November 03, 2015 - Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000 … Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000 … https://psnet.ahrq.gov/issue/vaccination-errors-reported-vaccine-adverse-event-reporting-system-vaers … united-states-2000 Vaccination-related errors reported to the National Vaccine Adverse Event Reporting System … https://psnet.ahrq.gov/issue/vaccination-errors-reported-vaccine-adverse-event-reporting-system-vaers-united-states

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33663/psn-pdf
     September 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, … Protestant not-for-profit health care system in the United States. … within a health system." … Patient Safety OfficerAdventist Health System References Back to Top 1. … Adventist Health System 2006 Annual Report. Adventist Health System Web site.

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42646/psn-pdf
     October 23, 2013 - System-related factors contributing to diagnostic errors. … System-related factors contributing to diagnostic errors. … https://psnet.ahrq.gov/issue/system-related-factors-contributing-diagnostic-errors This review describes … methods to address system and cognitive weaknesses in the diagnostic process. … https://psnet.ahrq.gov/issue/system-related-factors-contributing-diagnostic-errors

396. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36617/psn-pdf
     January 14, 2011 - Quest for the ideal: a redesign of the medication use system. … Quest for the ideal: a redesign of the medication use system. J Nurs Care Qual. 2007;22(1):11-19. … https://psnet.ahrq.gov/issue/quest-ideal-redesign-medication-use-system The authors describe the interdisciplinary … planning and redesign of their hospital's medication administration system. … https://psnet.ahrq.gov/issue/quest-ideal-redesign-medication-use-system

397. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35134/psn-pdf
     June 22, 2009 - Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. … Introduction of the medical emergency team (MET) system: a cluster- randomised controlled trial. … https://psnet.ahrq.gov/issue/introduction-medical-emergency-team-met-system-cluster-randomised- controlled-trial … They conclude that despite similar outcomes in both hospital groups, system-based interventions can … https://psnet.ahrq.gov/issue/introduction-medical-emergency-team-met-system-cluster-randomised-controlled-trial

398. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45639/psn-pdf
     February 17, 2017 - Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study … Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study … https://psnet.ahrq.gov/issue/dual-health-care-system-use-and-high-risk-prescribing-patients-dementia- … receive prescriptions for potentially unsafe medications than those who sought care only within the VA system … https://psnet.ahrq.gov/issue/dual-health-care-system-use-and-high-risk-prescribing-patients-dementia-national-cohort-study

399. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37666/psn-pdf
     April 02, 2008 - in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System … Safety in anaesthesia: a study of 12,606 reported incidents from the UK National Reporting and Learning System … psnet.ahrq.gov/issue/safety-anaesthesia-study-12606-reported-incidents-uk-national-reporting-and- learning-system … Though limited by the voluntary nature of the error reporting system, this study provides a basis for … psnet.ahrq.gov/issue/safety-anaesthesia-study-12606-reported-incidents-uk-national-reporting-and-learning-system

400. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46543/psn-pdf
     July 11, 2018 - Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation … Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation … https://psnet.ahrq.gov/issue/impact-inpatient-electronic-prescribing-system-prescribing-error-causation … human factors approach to characterize electronic prescribing errors, which were primarily due to CPOE system … https://psnet.ahrq.gov/issue/impact-inpatient-electronic-prescribing-system-prescribing-error-causation-qualitative