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Showing results for "system".

461. 3 Key Takeaways from the July 2018 Webcast: New SOPS HIT Patient Safety Supplemental Items for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast-keytakeaways.pdf
     August 01, 2018 - hospital providers and staff to address the following topic areas: Electronic Health Record (EHR) System … Training EHR System Support & Communication EHR Patient Safety & Quality Issues EHR & Workflow/Work … Process Overall EHR System Rating 2 What did we learn from the pilot test? … In the past 3 months... 66% discovered incomplete information in their EHR system 61% discovered

462. Weighted Summary Statistics: PUF Medicaid Outpatient File (Version 2) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-PUF-Summary-Statistics-Medicaid-Outpatient-Weighted.pdf
     September 26, 2023 - 38.23 K00-K95: Diseases of the digestive system 7,901,459 5.14 66,655,459 43.37 L00-L99: Diseases … and connective tissue 12,909,979 8.40 83,820,961 54.54 N00-N99: Diseases of the genitourinary system … 38.23 K00-K95: Diseases of the digestive system 7,901,459 5.14 66,655,459 43.37 L00-L99: Diseases … and connective tissue 12,909,979 8.40 83,820,961 54.54 N00-N99: Diseases of the genitourinary system … 62.52 K00-K95: Diseases of the digestive system 4,003,687 2.61 100,075,513 65.12 L00-L99: Diseases

463. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - Slide 6 Individual Mistake or System Failing? … While no system is perfect, we build redundancies into the care delivery system to compensate for minor … Slide 16 System Factors Impact Safety SAY: Each level of the health care delivery system matters. … Because emergencies strain any system. … The focus is on the system, not on the individuals.

464. Chapter 6. Measure Maps and Profiles (continued, 20) | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6s.html
     June 01, 2014 - Mapping Table   Measurement Perspective: Patient/Family Health Care Professional(s) System … Inpatient Registry). 1 Date: Measure released in 2007 2 and updated in 2010. 1 Perspective: System … measuring and reporting care coordination, released in September 2010. 3 Link to Outcomes or Health System … NQF preferred practices and performance measures set, released in September 2010. 1 Perspective: System … NQF preferred practices and performance measures set, released in September 2010. 1 Perspective: System

465. Appendix B7: Wheelchair Seating Assessment (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manwsa.html
     December 01, 2017 -   Adjustment to angle of w/c back __  Wheelchair with adjustable back __  Adjustable back seating system … Other ________________________________ Reason: Asymmetrical Trunk or Scoliosis   __  Deeper back system … with lateral supports __  3-point support system a __  Lateral support with accommodation on opposite …   Adjustment to angle of w/c back __  Wheelchair with adjustable back __  Adjustable back seating system … Attach supports to chairback or back support system. b Durable Medical Equipment.

466. CAUTI Prevention Implementation in a Community Hospital
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-060314.pptx
     March 01, 2009 - found inside patients’ bodies after operations. 4 Health Care Defects 5 In the U.S. health care system … Second order problem solving Fixing the immediate problem Fixing the system factors that allowed the … Get from the dance floor to the balcony level Individual challenges System challenges 27 Science … Summary 31 Safety is a property of system We need lenses to see the system We need to provide a safe … To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

467. Understand the Science of Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
     July 01, 2018 - Understand the Science of Safety module of the CUSP Toolkit discusses the importance of understanding system … System-Level Factors Affect Safety 9 Slide 8. Safety is a Property of the System Slide 9. … System-Level Factors Can Predict Performance Slide 10. … Yet, despite these advancements, our health care system is still plagued with defects that limit the … Return to Contents   Slide 8: Safety is a Property of the System Do: Play the video.

468. Advances in Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/index.html
     August 01, 2017 - Liability Preface Acknowledgments Prologue Silence A Commentary Reforming the Medical Liability System … Communication, Apology, and Resolution (CARe) Planning and Implementing the Patient Advocacy Reporting System … in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … Improving Communication Commentary: Silence Carole Hemmelgarn Reforming the Medical Liability System … Van Niel Planning and Implementing the Patient Advocacy Reporting System ® in the Sanford Health System

469. Preface | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/preface.html
     August 01, 2017 - Liability Preface Acknowledgments Prologue Silence A Commentary Reforming the Medical Liability System … Communication, Apology, and Resolution (CARe) Planning and Implementing the Patient Advocacy Reporting System … in the Sanford Health System Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse … efforts to deliver high-quality, evidence-based care, patients continue to be harmed by the health care system … To address the need to improve patient safety and the medical liability system, the AHRQ Patient Safety

470. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     December 01, 2017 - The system remains the same, at risk for harming a patient. … 6 Individual Mistake or System Failing? … While no system is perfect, we build redundancies into the care delivery system to compensate for minor … Because emergencies strain any system. … The focus is on the system, not on the individuals.

471. Creating Safety in the Testing Process in Primary Care Offices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Elder_18.pdf
     February 19, 2008 - This larger system has a significant impact on patient care. … .25 The testing process can be described as a distributed cognitive system or a work system, where multiple … existed or because they found the existing system ineffective or cumbersome. … Work system design for patient safety: The SEIPS model. … To err is human: Building a safer health system.

472. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
     March 31, 2008 - .1 They found that errors involving clinical decisions (as opposed to system process errors) were more … ASIPS Patient Safety Reporting System The core of the ASIPS PSRS is a Web-based data collection and … data management system, described in detail elsewhere.11 Briefly, the system accepted both anonymous … system was used intermittently (inadequate system), or the system output was ignored by the staff ( … system overridden or ignored).

473. New AHRQ SOPS® Workplace Safety Supplemental Item Set for Nursing Homes - Caren Ginsberg, Ph.D. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-ginsberg.pdf
     January 01, 2015 - ► 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 … Learning System AHRQ’s Surveys on Patient Safety Culture™(SOPS®) Program Agency for Healthcare Research

474. Understand-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
     May 01, 2017 - Safety module of the AHRQ Safety Program for Perinatal Care discusses the importance of understanding system … design affects system results, List the principles of safe design and identify how they apply to technical … Slide 2 SAY: Examples of the effect of defects and errors in the U.S. health care system are illustrated … Slide 4 SAY: According to the Science of Safety— Every system is perfectly designed to achieve its … Being cognizant of the system design and how it contributes to the results that it delivers will help

475. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - We implemented an electronic, Web-based event reporting system at five University of California medical … Given the endemic nature of latent system errors in our current health care delivery system, it is no … To err is human: building a safer health system. … A system for analyzing medical errors to improve GME curricula and programs. … Barriers to incident reporting in a healthcare system.

476. Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
     December 01, 2012 - Engineering System Design to Support Behavior Choices Slide 11. … Human error is a product of both system design and behavioral choices. … System design. Behavioral choices. Learning systems. Accountability and justice. … Transparency is also vital in addressing system factors that may contribute to harm. … Explain how system design affects system results.

477. Chapter 6. Measure Maps and Profiles (continued, 13) | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6l.html
     June 01, 2014 - Table   Measurement Perspective: Patient/Family Health Care Professional(s) System … Link to Outcomes or Health System Characteristics: None described in the sources identified. … Table   Measurement Perspective: Patient/Family Health Care Professional(s) System … as, “‘troubles" or "bothers" that patients experience during their encounters with the health care system … Primary care attributes, health care system hassles, and chronic illness.

478. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-slides.pptx
     January 01, 2017 - Objectives After this session, you will be able to— Understand and apply the Science of Safety Identify how system … Science of Safety ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 5 Institutional System … system is perfectly designed to achieve its end results Standardization, independent checks, and learning … Safety ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 10 Safety Is a Property of the System … Safety Is a Property of the System http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit

479. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
     January 25, 2008 - Methods: Analysts from the Pennsylvania Patient Safety Reporting System (PA-PSRS) mapped 420 reports … The Pennsylvania Patient Safety Authority developed the Pennsylvania Patient Safety Reporting System … This option would require a wholesale system overhaul of the current reporting system to make it into … an electronic front-end entry system for a PSET database. … of a large volume near-miss reporting system.

480. AHRQ Safety Program for Perinatal Care: Rapid Response for Perinatal Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse.pptx
     October 01, 2017 - The training materials and tools in this bundle review the key elements of a rapid response system within … A rapid response system (RRS) includes four components:1,2 A mechanism for activating a clinical team … System is established as part of a hospital’s larger rapid response system, or is established as a separate … Rapid Response Perinatal Safety 18 Unit Next Steps Decide whether to select the rapid response system … Support implementation of unit rapid response system through: Staff training/communication Simulation