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www.ahrq.gov/news/newsroom/case-studies/cp31309.html
January 01, 2020 - One of the ways it did so is by offering providers without an EHR system access to a “virtual health … A total of 305 clinical offices and 39 hospitals were entering data into the system in late 2012. … The system went live in May 2010. … Mark’s Family Medicine adopted an EHR system in 2007. … For providers with an EHR system, UHIN’s cHIE became a separate, almost parallel system that does not
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nemeth_116.pdf
April 27, 2008 - System-Level Safety
No system has infinite adaptive capacity. … In other words, plot how a system stretches in
response to changes in demands. … Equipment and information system design. … Human system integration in
the system development process: A new look. … Building a better delivery system: A new engineering
healthcare partnership.
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www.ahrq.gov/hai/cusp/modules/apply/alt-text.html
March 01, 2013 - Understand Just Culture
(vignette still)
Video icon
Slide 5
Just Culture 1
A system … Human error is the product of our current system design and behavioral choices. … Slide 8
Systems and Behaviors Work Together To Improve Outcomes 1
System Design
Mission, … Learning systems, like mission, values, and expectations, affect system design and in turn, behavioral … Slide 9
Peer to Peer Coaching
(vignette still)
Video icon
Slide 10
Engineering System
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-section-1-tables-6-10.pdf
April 17, 2019 - Detail
ICD-9-CM
Code
Amebic brain abscess 006.5
Tuberculosis of meninges and central nervous system … 036.0
HIV 042
Meningitis due to enterovirus 047
Other enterovirus diseases of the central nervous system … 048
Other non-arthropod-borne viral diseases of central nervous system 049
Postvaricella encephalitis … thrombosis of intracranial
venous sinus
437.6
Other congenital anomalies of the
circulatory system … of the aorta 747.1
Other anomalies of the aorta 747.2x
Other specified anomalies of
circulatory system
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Prologue_Henriksen_Vol1.pdf
July 10, 2008 - Also spanning the surveillance landscape are papers on a
national medication error reporting system, … proactive medication studies, a system that embeds
the principles of high-reliability organizations … , another that targets high-risk device-use areas, a
close call-good catch system, and a care enhancement … Attempting to map from one system to another
is not a task for the light-hearted. … vulnerabilities, and
how a mentor program can help staff navigate a reporting system while alleviating
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www.ahrq.gov/patient-safety/resources/resdesign-tool/index.html
August 01, 2016 - Redesign in Health Care: Final Report
Introduction
Description of Denver Health
Forces Which Compel System … Planning Steps
Strategies for Translating Information Into Proposed Projects for Implementation
System … for Healthcare Research and Quality (AHRQ) by Denver Health, a partner in AHRQ's Integrated Delivery System … September 2005
Contents
Introduction Description of Denver Health Forces Which Compel System Redesign … Redesign Implementation Strategies for Translating Information Into Proposed Projects for Implementation System
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/e1_combo_monitorprogress.pdf
June 05, 2016 - This tool provides the
following information:
• An overview and rationale for a monitoring system … to sustain improvements;
• Identification of the key elements of a monitoring system; and
• Guidance … on how to establish each monitoring system element. … There is no single “correct” way to build a system for monitoring sustainability of performance. … Consider both process and outcome measures for
inclusion in your monitoring system.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/e1_pdi_monitorprogress.pdf
June 05, 2016 - This tool provides the
following information:
• An overview and rationale for a monitoring system … to sustain improvements;
• Identification of the key elements of a monitoring system; and
• Guidance … on how to establish each monitoring system element. … There is no single “correct” way to build a system for monitoring sustainability of performance. … Consider both process and outcome measures for
inclusion in your monitoring system.
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www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/understand-sci-slides.html
May 01, 2017 - Explain how system design affects system results. … Slide 5: The Science of Safety
Every system is perfectly designed to achieve its end results. … Slide 6: System-Level Factors Affect Safety 6
Image: Concentric circles show the layered impact of … Slide 7: System-Level Factors Can Predict Performance
Examples of Impact of System-Level Factors … To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
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www.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
May 01, 2016 - Staff rated the new system favorably. … old system. … Multicare Health System. … By implementing a patient reporting system throughout Sanford Health System—a large,
not-for-profit, … Although one-third of respondents indicated the new system improved on the previous system,
two-thirds
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - Staff rated the new system favorably. … old system. … Multicare Health System. … By implementing a patient reporting system throughout Sanford Health System—a large,
not-for-profit, … Although one-third of respondents indicated the new system improved on the previous system,
two-thirds
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www.ahrq.gov/patient-safety/reports/hotline/intro1.html
May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient … Contents
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System … Although consumer reporting has the potential to increase knowledge about system failures amenable to … for patient safety events, using previously determined recommendations for such a system. … Appendix A includes the RTI recommendations for an ideal consumer reporting system.
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www.ahrq.gov/news/newsletters/e-newsletter/660.html
April 01, 2019 - April 16, 2019
AHRQ Stats: Health System Participation in Accountable Care Organizations … Health Systems— Health System Participation in Accountable Care Organizations (ACOs), 2016 .) … Fewer Errors Seen in Computerized Prescribing System That Selects Medications Based on Indications . … Fewer Errors Seen in Computerized Prescribing System That Selects Medications Based on Indications … The data also are available on HCUPnet , an online query system that is available at no cost.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/tiered-approach-notes.docx
April 01, 2022 - Designing a safe system is an essential component of achieving a positive safety culture. … A “Just Culture” is a system in which staff members and the system itself are held accountable. … System accountability encompasses leadership by its very nature. … Shared responsibility between staff and the system along with widespread commitment to eliminating the … Organizations can manage both system and human behavior through development of learning systems, which
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-maintenance-notes.docx
April 01, 2022 - In addition to proper insertion, contamination can occur due to breaks in the collection system. … In the next slide, we’ll examine some challenges related to maintaining a closed system. … the closed system, especially in the ICU setting. … Irrigation is always a challenge, but if the seal is broken, it is advisable to change the system. … However, if the seal is broken, it is advisable to change the catheter and the collection system.
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www.ahrq.gov/news/newsroom/case-studies/cp31301.html
January 01, 2020 - SAFEHealth (Secure Architecture for Exchanging Health Information), a health information exchange (HIE) system … vast majority of patients who split their care between the two organizations opt to participate in the system … clinical data safely stored behind the security firewalls of each health care provider's information system … SAFEHealth connects Reliant's electronic health records (EHR) directly to HealthAlliance's system. … The system also has extensive audit trails to help monitor patient privacy.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Daudelin.pdf
January 01, 2000 - However, a condition- or problem-
oriented IT system might better integrate into the care of frequent … System installation
Installation of the TIPI-IS at each site included seven steps:
1. … for use in a patient safety system. … The disadvantage of the Web-based system was the perception that it was
difficult to access the system … while still ensuring the security of the system.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
March 01, 2004 - A primary goal was the creation of
a standardized medication event reporting system, including a central … Although the challenges associated with the implementation of a
standardized error reporting system … medication errors reported through the MEDMARX system
has increased dramatically (Figure 1). … The USP has incorporated numerous changes to the MEDMARX
system since it was launched in 1998. … To err
is human: building a safer health system.
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-implementation-guide.pdf
March 01, 2023 - in your hospital/health system. … • IT Lead/Staff possess deep understanding of the EMR system. … • Clinical Staff are the ultimate users of the referral system. … (This is crucial for tracking the effectiveness of the AR
system.) … Check that your new AR
build aligns with how providers use the system.
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6a.html
June 01, 2014 - Mapping Table
Measurement Perspective:
Patient/Family
Health Care Professional(s)
System … Date: Measure released in 2000. 1
Perspective: System Representative(s)
Measure Item Mapping: … Paired t-tests were used to evaluate the sensitivity of the ACIC to detect system improvements. … Testing revealed that all six subscale scores were responsive to system improvements made by care teams … Date : Measure released in 2001. 1
Perspective: System Representative(s)
Measure Item Mapping: