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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
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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.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14053-Gandhi-draft-1.pdf
April 16, 2007 - Gandhi 4.16.07
1
Scope: BWH developed a homegrown barcode/eMAR system to allow full integration … with
the existing CPOE system. … The Brigham and Women’s hospital pharmacy converted to the barcoding system
in September 2003. … A barcode-assisted dispensing
system was implemented in three configurations. … The Medication Administration System--
Nurses Assessment of Satisfaction (MAS-NAS) scale.
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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.
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www.ahrq.gov/patient-safety/resources/resdesign-tool/kit4.html
August 01, 2016 - Does the system have the resources to undertake the redesign process? … Implementation of an open access system.
Diabetes disease management system. … What system metrics should we use to measure success? … These tools are frequently utilized in the Toyota Production System. … Lean (or the Toyota Production System) .
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/harrison-summit2016-breakout.pdf
September 28, 2016 - for thinking about
organizational factors
• Research Examples: Foundations for future
work
Work System … community pharmacies,
and ambulatory surgery centers
• Teamwork
► TeamSTEPPS®: evidence-based teamwork system … evidence-based
medicine
o Initiative will develop a “Compendium” that will enable users to
access health system … Appendix: AHRQ Resources
• Comparative Health System Performance Initiative
http://www.ahrq.gov/professionals … www.ahrq.gov/carecoordination
Organizational Factors Affecting Diagnostic Quality
Overview
Work System
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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
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/about/CAHPS-Database-Brief_01_2014.pdf
January 01, 2014 - The
CAHPS Database includes an Online
Reporting System displaying
aggregated data to facilitate
comparisons … The CAHPS Online Reporting
System is a Web-based platform for
viewing Health Plan and Clinician … The reporting
system consists of two major
components:
a public site available to anyone
with … Database are
provided access to a secure,
password-protected area of the
CAHPS Online Reporting System … CAHPS Health Plan Survey Component
CAHPS Clinician & Group Survey Component
CAHPS Online Reporting System
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www.ahrq.gov/news/newsroom/case-studies/cp30909.html
October 01, 2014 - MSeHA is a nonprofit, community-wide information system providing an electronic exchange of information … A total of 321 clinicians have used the system in five emergency departments since its initial deployment … Sands appreciates several aspects of the exchange, including how quickly data is entered into the system … The system has both inpatient and outpatient records; thus, I can see how compliant the patients are. … The system permits providers to review medical information faster than by individually contacting a patient's
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www.ahrq.gov/research/findings/final-reports/prospectscare/prospects1.html
July 01, 2018 - Lack of data standardization and limited health IT system interoperability. … Return to Contents
Key Challenge Area 1: Underutilization of Health IT System Capabilities and … Challenge 1d: Underrepresentation of nonphysician viewpoints in health IT system design
One panelist … Recommendations to Address Key Challenge Area 1: Underutilization of Health IT System Capabilities and … This variation stems partially from system customization that takes place during implementation.
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www.ahrq.gov/patient-safety/capacity/candor/demo-program/plan-grants/appa.html
May 01, 2016 - 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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care
Science of Safety
Health Care Defects
In the U.S. health care system … patient
4
AHRQ Safety Program for Perinatal Care
Science of Safety
4
The Science of Safety
Every system … Factors Affect Safety6
6
AHRQ Safety Program for Perinatal Care
Science of Safety
6
System-Level … Factors Can Predict Performance
Examples of Impact of System-Level Factors
System Factor Effect
Nurse-to-patient … 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/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
February 02, 2018 - GAPPS study analytic sample (n=
3,442)
Chronic Condition Indicators n (%) AE rate P-Value
0 body system … 1,935 (56.2%) 0.07 Reference
1 body system 1,067 (31.0%) 0.12 <0.001
2 body systems 315 (9.2%) 0.25 … analytic sample (n= 3,442)
Chronic Condition Indicators
(CCI)
RRa (95% CIb) P-Value
0 body system
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www.ahrq.gov/sites/default/files/publications/files/ambulatory-safety.pdf
July 01, 2010 - Funding: $986,302
Designs, develops, implements, and
evaluates an interoperable quality
information system … Adverse Drug Events
in Ambulatory Pediatrics
Estimated Total Funding: $992,699
Uses a computerized system … Dates: 9/30/2007–12/31/2009
Electronic Support for Public Health
- Vaccine Adverse Event Reporting
System … Focus Areas: AQA starter set for
primary care (26 measures)
Type of Health IT: System integration,
quality … Focus Area(s): Patient self-management;
shared decisionmaking
Type of Health IT: System architecture,
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Slide 7: Individual Mistake or System Failing? … While no system is perfect, we build redundancies into the care delivery system to compensate for minor … Slide 17: 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.
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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.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
April 21, 2008 - The prototype included an event reporting system (the Medical
Events Reporting System - Total HealthSystem … MERS-TH is a unique reporting system, since it is also a
comprehensive error management system. … • Computerized charting system. … Trending and investigation reports are
produced through the Midas system. … System changes are made as issues are identified.”
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/pa-specialinnovation.pdf
August 01, 2015 - Sites gradually transitioned to the new system
between 2011 and 2013, so the two different methods … 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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
January 01, 2007 - Abstract
This article describes challenges in the design and development of a decision support system … Future testing and
development of this system will include a randomized clinical trial and technology … Introduction
The development, testing, and validation of a real-time decision support system for use … The decision support system
described in this article is part of the Trauma Reception and Resuscitation … Building a flexible protocol
information system with ready for use web
technology.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-154-section-7-b-icd-9-codes.pdf
July 13, 2018 - 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