-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
June 15, 2003 - Reporting systems
To identify system failures &
unsafe conditions that could
lead to system failures … The CDC has also invested heavily in improving the NNIS system. … that could lead to system failures … To err
is human: building a safer health system. … Large system change and a culture of
safety.
-
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/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/cusp/clabsi-hpwpreport/clabsi-hpwptab1.html
August 01, 2015 - Management (11)
Staff (14)
Site 3 (2)
Higher performance
Regional multisite health system … Staff (12)
Site 6 (3)
Higher performance
Community hospital, part of large Catholic system … 10)
Site 7 (4)
Higher performance
Inner-city safety net hospital, part of regional system … (3)
Management (9)
Staff (10)
Site 8 (4)
Lower performance
Part of multistate system … a A safety net hospital or health system provides a significant level of care to low-income, uninsured
-
www.ahrq.gov/news/newsletters/e-newsletter/832.html
September 01, 2022 - AHRQ Announces New Healthcare System Challenge Competition . … AHRQ Announces New Healthcare System Challenge Competition
AHRQ’s newest challenge competition will … Incorporating unpublished healthcare system data into systematic review findings may be particularly … data to address relevant problems in the applicant’s healthcare system. … The second phase requests an analysis of healthcare system data alongside systematic review findings
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS_Hospital_Survey_2-0-HIT.docx
June 09, 2016 - We are given enough training on how to use our EHR system
1
2
3
4
5
9
2. … There are too many alerts or flags in our EHR system
1
2
3
4
5
9
SECTION J: EHR System Support … We are asked for input on ways to improve our EHR system
1
2
3
4
5
9
3. … K: Overall EHR System Rating
1. … How satisfied or dissatisfied are you with your hospital’s EHR system?
-
www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
August 01, 2022 - By implementing a patient reporting system throughout Sanford Health System—a large, not-for-profit, … the Sanford Health System. … Prepared by Jackson Health System under grant number 1R21 HS19506-01. … Although one-third of respondents indicated the new system improved on the previous system, two-thirds … cases processed through the old system.
-
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/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/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
-
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/news/newsletters/e-newsletter/672.html
July 01, 2019 - Learn How HCA Healthcare Improved System Processes To Provide Better Care . … Learn How HCA Healthcare Improved System Processes To Provide Better Care
HCA Healthcare, a for-profit … healthcare system based in Nashville, is among organizations featured in a series of AHRQ case studies … Featured Studies on the Nation's Health Systems
AHRQ's Comparative Health System Performance Initiative … Hospitals' adoption of intra-system information exchange is negatively associated with inter-system information
-
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/sites/default/files/wysiwyg/evidencenow/results/research/practice-survey-part1-mw.pdf
July 20, 2018 - Does your practice use an EHR system or EMR system? Do not include billing record
systems. … In which year did you install your current EHR/EMR system? ___________________
11. … What is the name of your current EHR/EMR system? … What version of your EHR/EMR system are you currently using? … At your practice are there plans for installing a new EHR/EMR system within the next 18 months?
-
www.ahrq.gov/patient-safety/reports/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/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/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/pqmp/measures/acute/chipra-207-section-7-icd-codes.pdf
June 14, 2019 - septal closure
746 Other congenital anomalies of heart
747 Other congenital anomalies of circulatory system … Anencephalus & similar anomalies
741 Spina bifida
742 Other congenital anomalies of the nervous system … 748 Congenital anomalies of respiratory system
749 Cleft palate & cleft lip
750 Other congenital … anomalies of upper alimentary tract
751 Other congenital anomalies of digestive system
756 Other … congenital anomalies of musculoskeletal system
758 Chromosomal anomalies
759 Other unspecified congenital
-
www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
May 01, 2017 - Safety module of the AHRQ Safety Program for Perinatal Care discusses the importance of understanding system … Explain how system design affects system results. … Health Care Defects
Say:
Examples of the effect of defects and errors in the U.S. health care system … Being cognizant of the system design and how it contributes to the results that it delivers will help … there are several system factors that simultaneously influence unit culture and patient safety.
-
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.