-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-datasources.pdf
October 01, 2019 - Description
The Behavioral Risk Factor Surveillance System (BRFSS) is the Nation’s premier system of … Description
The Uniform Data System (UDS) is an integrated reporting system used by all grantees of … Resource and Patient Management System (RPMS) and National Patient Information Reporting
System (NPIRS … Description
The Medicare Patient Safety Monitoring System (MPSMS) is a nationwide surveillance system … The system tracks and monitors interactions with the healthcare
system rather than health conditions
-
www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6t.html
June 01, 2014 - Mapping Table
Measurement Perspective:
Patient/Family
Health Care Professional(s)
System … and data collected from the medical record. 1
Date: Measure released in 2009. 1
Perspective: System … measuring and reporting care coordination, released in September 2010. 2
Link to Outcomes or Health System … Perspective:
Patient/Family
Health Care Professional(s)
System Representative(s)
Care … Melanoma Continuity of Care—Recall System
Purpose: To measure the percentage of patients, regardless
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
December 01, 2020 - Resource and Patient Management System (RPMS) and National Patient Information Reporting
System (NPIRS … Data system home page: https://www.usrds.org. … System. … The system
tracks and monitors interactions with the healthcare system rather than health conditions … Statistics System: Mortality (NVSS-M)
National Vital Statistics System: Natality (NVSS-N)
Centers
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
January 01, 2007 - Abstract
Since 2004, we have managed a voluntary Web-based medical adverse event (AE) reporting
system … Event rates in this passive surveillance system were
substantially lower than have been reported in … Report Management [ORM] system by Quantros, Inc., a reporting software vendor)
and provided it free … The latter was not necessarily the number of
hospitals participating in the system. … To err is human: Building a safer
health system.
-
www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
January 01, 2024 - Methods: Narrative data were structured and coded using the MedLEE NLP system and merged with other … We may then use these descriptions to learn how to improve the automated system. … The system is able to apply the criteria to 30,000 discharge summaries in 4 minutes. … Case retrieval for medical event reporting systems: an
evaluation of the HAWK system. … The system requires that the researcher obtain a license for the MedLEE natural language processing system
-
www.ahrq.gov/sites/default/files/2024-02/gandhi-report.pdf
January 01, 2024 - The system development took
approximately 1 year. … the initial study phase, four outpatient primary care clinics
affiliated with Partners HealthCare System … Currently, there are seven practices using the system. … During
the study phase, four clinics opted to implement the outpatient order entry system integrated … Once the physician has
clicked this button, the ACPOE system automatically generated the medication
-
www.ahrq.gov/sites/default/files/2024-07/morrison-report.pdf
January 01, 2024 - This system will enhance each provider’s ability to provide the best care possible.
2
This work … The
group consisted of system analysts and network engineers from each partner
organization. … Results
Our pilot studies have shown that, in order to be successful, the system must have
minimal … • Providers must be shown the benefits of this new system. … We believe that
automation of the system is vital to acceptance.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applycusp.pptx
August 18, 2011 - Introduction to Just Culture Principles
3
3
Understand Just Culture
4
4
Just Culture1
A system … 7
Systems and Behaviors
Work Together To Improve Outcomes1
8
Mission, Values,
and Expectations
System … Improved
Outcomes
Learning
Systems
Accountability
and Justice
8
Accountability
10
Engineering System … Transparency is impossible
Blame-Free Culture: No accountability
Just Culture: Optimally supports a system … design affects system results
List the principles of safe design and identify how they apply to technical
-
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/slides.html
October 01, 2020 - Build a measurement system
– Who, what, when, how to measure. … Establish robust followup and transparent feedback system. … processes: Are the parts or steps in the system performing as planned? … What happened to the system as we improved the outcome and process measures? … – A process for collecting, reporting, and inputting data into system database.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
March 18, 2008 - Beginning in 2003, Denver Health implemented a commercially available CPOE system. … Efficiencies of the system support better patient safety and quality of care. … To err is
human: Building a safer health system. Washington,
DC. … Crossing the quality chasm: A
new health system for the 21st century. Washington,
DC. … Effects of an integrated clinical information system on
medication safety system in a multi-hospital
-
www.ahrq.gov/patient-safety/reports/liability/crane.html
August 01, 2017 - Liability
Preface
Acknowledgments
Prologue
Silence A Commentary
Reforming the Medical Liability System … in the Sanford Health System
Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … We designed and implemented an anonymous, near-miss reporting and improvement tracking system in seven … To Err is Human: Building a Safer Health System. … "Every error counts": a web-based incident reporting and learning system for general practice.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
January 01, 2004 - (NYPORTS) mandatory adverse event reporting system to include the reporting
of medication errors. … fixes instead of punitive
fixes or inappropriate/incomplete system fixes. … and not the system. … To err
is human: building a safer health system. … Albany (NY): New York
Patient Occurrence Reporting and Tracking System.
c2000–2002.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie.pdf
June 01, 2023 - ■ A computerized, bar-code-based tracking system for blood transfusions was used to prevent patient … integrated with a clinical decision support system in an
outpatient EHR improved care quality, test … The CPOE system was fully implemented in the facility
by 2010, including for chemotherapy orders, and … System (LIMS) to identify and warn
pharmacists of possible errors. … https://digital.ahrq.gov/ahrq-funded-projects/toward-optimal-patient-safety-information-system
7
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-2.html
March 01, 2022 - diagnosis requires a deep understanding of how people interact with one another and within the health system … Finally, the healthcare system has a defining influence on clinical reasoning and diagnosis. … and that those completing health professions education programs can easily navigate the healthcare system … Improved awareness of such impact would better equip healthcare administrators and system leaders to … effectively mitigate harmful effects of system factors on diagnostic performance and ensure these leaders
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-slides.html
February 01, 2017 - Identify how system factors and design affect patient outcomes. … Slide 6: System Factors Impact Safety 2
Image: A series of small circles around a larger circle captioned … Slide 7: Apply System Lenses
Engage staff by asking them to apply systems lenses with the following … system is perfectly designed to achieve its end results. … Slide 11: Safety Is a Property of the System
Safety Is a Property of the System
http://www.ahrq.gov
-
www.ahrq.gov/patient-safety/resources/learning-lab/transdisciplinary-learning-long-desc.html
June 01, 2020 - Develop and implement an indicator of unit-level stress in an engineered care system to predict and mitigate … interoperability. 2-4 The Smart Agent system dynamically controls insulin infusions to reduce the time … Nurses found the Smart Agent system more efficient, safe, and usable than the current standard-of-care … They found the new system less demanding in terms of workload. … Operating management system for high reliability: Leadership, accountability, learning and innovation
-
www.ahrq.gov/hai/cusp/modules/apply/sl-cusp.html
December 01, 2012 - Engineering System Design to Support Behavior Choices
Slide 11. … Just Culture 1
A system that:
Holds itself accountable. … Systems and Behaviors Work Together To Improve Outcomes 1
System Design. … Just Culture: Optimally supports a system of safety.
Slide 11. … Explain how system design affects system results.
-
www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/pa-specialinnovation.html
August 01, 2018 - Grant, 12 of CHOP’s primary care offices began implementing a fully-automated electronic screening system … Providers reported that the fully-automated electronic system minimized the amount of time that they … The electronic system also supports billing during the screening encounter and the ability to review … Families reported that the electronic system was easy to use and it allowed them to feel more involved … with 12 practices before going system-wide.
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/healthy-aging-roundtable.pdf
September 08, 2022 - .........................................................4
Developing a Truly Person-Centered Care System … Bierman highlighted the vital need for disruption and innovation in a system not designed to
foster … In a system where an estimated 25
percent of all spending is wasted, 2 opportunities exist to capture … Waste in the US Health Care System Estimated Costs and Potential for Savings. … would
look like; hearing person and community voices; hearing clinician, practice, and health system
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/2-sops101-webcast-2023-ginsberg.pdf
January 01, 2023 - ► The lead Federal agency charged with improving the safety and quality of
America’s healthcare system … Generate measures and data to track and
improve performance, and evaluate progress of the US health
care system … improvement to all settings
• Prevent HAIs, reduce antibiotic resistance
• Build capacity in the health care system … Determines
behaviors
that are:
Rewarded Supported Expected Accepted
Exists at
multiple
levels:
System