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Showing results for "system".

41. A health system that won't learn from its mistakes. | PSNet
    psnet.ahrq.gov/issue/health-system-wont-learn-its-mistakes
    October 26, 2022 - Commentary A health system that won't learn from its mistakes. … A health system that won't learn from its mistakes. … for improvement such as assignment of accountability for error and commitment to the learning health system … A health system that won't learn from its mistakes.

42. Patient Safety Reporting System. | PSNet
    psnet.ahrq.gov/issue/patient-safety-reporting-initiative
    September 12, 2016 - Multi-use Website Patient Safety Reporting System. … Citation Text: Patient Safety Reporting System. … Cite Citation Citation Text: Patient Safety Reporting System … May 18, 2018 Indiana Medical Error Reporting System. … January 18, 2012 Indiana Medical Error Reporting System.

43. Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. | PSNet
    psnet.ahrq.gov/issue/mature-rapid-response-system-and-potentially-avoidable-cardiopulmonary-arrests-hospital
    July 20, 2022 - Study Mature rapid response system and potentially avoidable cardiopulmonary arrests … Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. … Implementation of a rapid response system (RRS, also known as medical emergency team) is intended to … Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. … rapid response system.

44. Screening for medication errors using an outlier detection system. | PSNet
    psnet.ahrq.gov/issue/screening-medication-errors-using-outlier-detection-system
    December 18, 2019 - Study Screening for medication errors using an outlier detection system. … Screening for medication errors using an outlier detection system. … The charts were reviewed using a coding system to evaluate the utility of the alerts generated. … About 75% of the chart-reviewed alerts created by the screening system identified possible medication … Screening for medication errors using an outlier detection system.

45. Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy. | PSNet
    psnet.ahrq.gov/issue/multidisciplinary-system-detecting-medication-errors-antineoplastic-chemotherapy
    March 09, 2022 - Study Multidisciplinary system for detecting medication errors in antineoplastic … Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy. … This study found that a multidisciplinary system with a computerized pharmacotherapy process intercepted … Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy. … June 10, 2018 Using an enhanced oral chemotherapy computerized provider order entry system

46. A system-wide hospital child maltreatment patient safety program. | PSNet
    psnet.ahrq.gov/issue/system-wide-hospital-child-maltreatment-patient-safety-program
    September 15, 2021 - Study A system-wide hospital child maltreatment patient safety program. … A system-wide hospital child maltreatment patient safety program. … This article describes the implementation of a system-wide daily review of patients with concerns of … A system-wide hospital child maltreatment patient safety program.

47. Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework. | PSNet
    psnet.ahrq.gov/issue/longitudinal-evaluation-pediatric-rapid-response-system-realist-evaluation-framework
    July 20, 2022 - Study Longitudinal evaluation of a pediatric rapid response system with realist evaluation … Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework. … Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework. … rapid response system. … rapid response system.

48. Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. | PSNet
    psnet.ahrq.gov/issue/effectiveness-barcode-medication-administration-system-reducing-preventable-adverse-drug
    December 14, 2022 - Study Effectiveness of a barcode medication administration system in reducing preventable … Effectiveness of a barcode medication administration system in reducing preventable adverse drug events … Implementing a bar coding system reduced adverse drug events by approximately 50% in this single-institution … Effectiveness of a barcode medication administration system in reducing preventable adverse drug events … events causing hospitalisation: identifying root causes and developing a surveillance and learning system

49. Reduction in omission events after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery. | PSNet
    psnet.ahrq.gov/issue/reduction-omission-events-after-implementing-rapid-response-system-mortality-review
    April 20, 2022 - Study Reduction in omission events after implementing a rapid response system: a … Reduction in omission events after implementing a Rapid Response System: a mortality review in a department … documentation of vital signs could be a barrier to successful implementation of a rapid response system … probing study of a hospital rapid response system. … rapid response system.

50. Radiation Oncology Incident Learning System. | PSNet
    psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
    April 22, 2020 - Multi-use Website Radiation Oncology Incident Learning System. … Citation Text: Radiation Oncology Incident Learning System. … Cite Citation Citation Text: Radiation Oncology Incident Learning System … January 17, 2017 Radiotherapy Incident Reporting and Analysis System. … Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system

51. System-related and cognitive errors in laboratory medicine. | PSNet
    psnet.ahrq.gov/issue/system-related-and-cognitive-errors-laboratory-medicine
    December 21, 2016 - Commentary System-related and cognitive errors in laboratory medicine. … System-related and cognitive errors in laboratory medicine. … This commentary discusses several approaches to decrease system and cognitive errors in clinical laboratories … System-related and cognitive errors in laboratory medicine. … February 13, 2019 Mind the overlap: how system problems contribute to cognitive failure

52. Flying lessons for clinicians: developing system 2 practice. | PSNet
    psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system-2-practice
    April 24, 2018 - Commentary Flying lessons for clinicians: developing system 2 practice. … Flying Lessons for Clinicians: Developing System 2 Practice. … that simulation is underutilized in health care training to help nurses to develop deliberate, or system … The authors review simulation practices to enhance nursing education strategies that support system … Flying Lessons for Clinicians: Developing System 2 Practice.

53. Five system barriers to achieving ultrasafe health care. | PSNet
    psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
    September 29, 2017 - Commentary Classic Five system barriers to achieving ultrasafe … Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-64. … This commentary builds on the notion that our health care system requires structured efforts to improve … in which one system achieves "ultrasafe" status while the other does not at a calculated and accepted … Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-64.

54. Medical error reporting system still a year off. | PSNet
    psnet.ahrq.gov/issue/medical-error-reporting-system-still-year
    July 10, 2013 - Newspaper/Magazine Article Medical error reporting system still a year off. … Citation Text: Medical error reporting system still a year off. Hansen D. … This article reports on the progress of implementing a voluntary system for reporting errors, part of … response system. … October 6, 2021 A system-wide hospital child maltreatment patient safety program.

55. Implementing SBAR across a large multihospital health system. | PSNet
    psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system
    November 23, 2014 - Study Implementing SBAR across a large multihospital health system. … Implementing SBAR across a large multihospital health system. … In this study, implementation of system-wide training and adoption of the structured communication … Implementing SBAR across a large multihospital health system. … May 25, 2013 Journey to no preventable risk: The Baylor Health Care System patient safety

56. Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. | PSNet
    psnet.ahrq.gov/issue/work-system-barriers-and-facilitators-inpatient-care-transitions-pediatric-trauma-patients
    September 11, 2019 - Study Work system barriers and facilitators in inpatient care transitions of pediatric … Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. … Nine dimensions of system barriers and facilities in care transitions were identified: anticipation; … Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. … February 16, 2022 Team cognition in handoffs: relating system factors, team cognition

57. Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt. | PSNet
    psnet.ahrq.gov/issue/reflections-implementing-hospital-wide-provider-based-electronic-inpatient-mortality-review
    August 12, 2020 - Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system … Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system … This paper discusses the implementation of a hospital-wide, automated electronic reporting system that … Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system … tiered huddle system on reporting patient safety events: an interrupted time series analysis.

58. Patient safety on the otolaryngology service: the role of an established rapid response system. | PSNet
    psnet.ahrq.gov/issue/patient-safety-otolaryngology-service-role-established-rapid-response-system
    October 19, 2022 - Patient safety on the otolaryngology service: the role of an established rapid response system … Patient safety on the otolaryngology service: the role of an established rapid response system. … Patient safety on the otolaryngology service: the role of an established rapid response system. … April 6, 2011 A 5-year analysis of rapid response system activation at an in-hospital … October 27, 2010 A survey of nurses' beliefs about the medical emergency team system

59. Integrating the intensive care unit safety reporting system with existing incident reporting systems. | PSNet
    psnet.ahrq.gov/issue/integrating-intensive-care-unit-safety-reporting-system-existing-incident-reporting-systems
    January 12, 2011 - Study Integrating the intensive care unit safety reporting system with existing incident … Integrating the intensive care unit safety reporting system with existing incident reporting systems. … The authors describe the implementation of an AHRQ-funded external reporting system in seven intensive … They found that the system improved error reporting and thus may enhance patient safety. … Integrating the intensive care unit safety reporting system with existing incident reporting systems.

60. Creating a web-based incident analysis and communication system. | PSNet
    psnet.ahrq.gov/issue/creating-web-based-incident-analysis-and-communication-system
    May 01, 2003 - Study Creating a web-based incident analysis and communication system. … Creating a web-based incident analysis and communication system. … This study reports on the development of a system for standardizing root cause analysis of sentinel … Creating a web-based incident analysis and communication system. … February 18, 2011 Safety of using a computerized rounding and sign-out system to reduce