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psnet.ahrq.gov/issue/patient-safety-begins-proper-planning-quantitative-method-improve-hospital-design
July 19, 2023 - View more articles from the same authors. … Usability testing, a key component of human factors engineering , is the process of testing new technology … 7 XML Endnote tagged PubMedId RIS
Download Citation
Related Resources From the … September 27, 2016
The use of a standard design medication room to promote medication … October 31, 2014
Understanding the Role of Facility Design in the Acquisition and Prevention
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psnet.ahrq.gov/issue/under-reporting-deaths-coroner-doctors-retrospective-review-deaths-two-hospitals-melbourne
April 24, 2018 - Study
Under-reporting of deaths to the coroner by doctors: a retrospective review … View more articles from the same authors. … of deaths that met the coroner's reporting criteria were not reported. … Such under-reporting limits the ability to detect preventable deaths. … The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020
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psnet.ahrq.gov/issue/establishing-multi-institutional-quality-and-patient-safety-consortium-collaboration-across
June 24, 2009 - View more articles from the same authors. … Primary goals of the consortium include to (1) expand learner-driven interprofessional opportunities … December 11, 2024
The impact of nursing skill-mix on adverse events in intensive care … July 29, 2020
You can't blame the wreck on the train. … March 3, 2011
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/nursing-home-staff-turnover-and-perceived-patient-safety-culture-results-national-survey
June 30, 2021 - View more articles from the same authors. … In this study, the Nursing Home Survey on Patient Safety Culture was used to assess the association … June 30, 2021
The July effect: an analysis of never events in the nationwide inpatient … February 12, 2020
Organizational readiness to change as a leverage point for improving … August 4, 2021
Still Failing the Frail.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - emergency department (ED) with fever and mental status change. … ordered at transitions in levels of care
Provides a method to communicate when an intentional medication change … cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14691892
Medication Reconciliation
Recommended change … for teams participating in IHI collaboratives to reduce adverse drug events
One of six changes chosen … list to aid in decisions about drug therapy and document reasons to discontinue, change, or hold medications
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psnet.ahrq.gov/issue/effects-patient-handoff-characteristics-subsequent-care-systematic-review-and-areas-future
January 19, 2011 - View more articles from the same authors. … Although use of standardized handoff sheets appeared to improve the quality of handoffs, the authors … The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis … August 2, 2017
View More
Related Resources
Shift change handovers … September 24, 2016
A systematic review of the literature on the evaluation of handoff
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - the
Lean principles.3 The Lean teams evaluated their workflows to find gaps that could be targeted with … with negative patient care outcomes.3 In addition, the Lean teams oversaw the implementation of the … innovating site is
committed to change, there is support from senior leadership, a multidisciplinary … Leaders to train multidisciplinary teams on the Lean CQI strategy. … Staff to participate in the Lean teams and create collaborative safety plans with patients.
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - While many patient safety interventions have used traditional models of effecting change, such as changing … to summon rapid response teams , rather than waiting for clinicians to respond. … The Agency for Healthcare Research and Quality and the World Health Organization sponsor a variety of … In addition to its prioritization of patient engagement through the National Patient Safety Goal, The … November 23, 2016
Experience with family activation of rapid response teams.
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - plan, however, there are cases in which decision-making capacity may change due to fluctuating mentation … the lack of multidisciplinary teams involved in a patient’s care. … For example, teams that do not include a social worker or mental health professional may not have the … and its prognosis, and the healthcare teams will have a better understanding of the values and goals … September 4, 2019
Measuring the teamwork performance of teams in crisis situations: a
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psnet.ahrq.gov/issue/healthcare-professionals-perception-safety-culture-and-operating-room-or-black-box-technology
March 02, 2022 - View more articles from the same authors. … Measuring psychological safety and local learning to enable high reliability organisational change … Improving the implementation and adherence of the surgical safety checklist: a quality improvement project … in the operating room. … October 6, 2016
Reliability of a revised NOTECHS scale for use in surgical teams.
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - internal capacity necessary to continue to drive change. … Hospital and system-level teams should review the data regularly to allow for
modification and refinement … to each hospital’s culture of
safety, organization, and readiness to change. … At the initiation of the HEN 2.0 contract, LifePoint established the NQP as the framework to not only … use of
interdisciplinary care teams, bedside shift reports, prioritizing patient engagement) and providing
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - rapid response teams? … Nurses who have actually participated in urgent response teams tell me that the outcomes for the patients … only 16% of hospital CEOs listed patient safety among their top three concerns in 2004—no significant change … response teams and the use of evidence-based strategies to prevent ventilator-associated pneumonia. … blueprint to guide culture change in the nurse practice environment.
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Safety, Radiology Quality and Safety, and the Center for Evidence-Based Imaging (CEBI) teams, identified … The focus of working group meetings is subject to change, and it may be
expanded or altered based on … input from data and information technology teams to
identify target patient populations. … For instance, duties conducted by grant staff were transitioned to operational teams. … Identify drivers of change to ensure patient safety and to minimize patient harm.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - The resident came to the floor, told the nurse she was “stupid” and confidently explained that the case … The attending then called the operating room to cancel the case. … Case: Difficult Encounters (5)
The following day, the CMO reviewed the nurse's intervention with the … today than in past
A few senior physicians have lost privileges
Safety innovations (rapid response teams … , time outs, etc.) have helped
Teamwork training has helped change culture
But more change is needed
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - , so the two teams opted to keep the gastrostomy tube for gastric venting and to place a nasojejunal … The patient’s spouse then called the surgery clinic to change the follow-up visit; he revealed that his … transhepatic PEG tube, which contributed to the change in the original management plan. … A third systems solution might be to minimize the number of teams that offer percutaneous enteral tube … risk of adverse events, care teams should implement tactics to minimize the risk of adverse events.
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Trauma teams have benefited from review of previous cases by
identifying defects in teamwork (7), just … like professional sport teams that routinely use video to review their
past performance. … illustrating technical procedures,
video is used for dissemination of best practices, such as bedside shift change … Structured, routine post-action reviews, either by individuals or by teams, are also becoming more
prevalent … appd001
https://psnet.ahrq.gov//#ref15
https://psnet.ahrq.gov//#ref3
become available, individuals and teams
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Teach students that the improved communication and teamwork skills that will support cultural change … RW: A lot of discussion in the patient safety world is about how to change the culture of physicians … I have personally seen a change, just in working with the committees that I'm on. … The technology will change the role of the pharmacist, to a greater focus on drug information provision … I was in New Zealand to give a talk, and because of the time change I couldn't sleep.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Transitions in Care
Shift change over
Two or more workers exchange mission-specific information, responsibility … Practices of high reliability teams: observations in trauma resuscitation. … stage
Clinicians content with diagnosis of urinary tract infection for explanation of mental status change … change was due to urinary tract infection. … for this patient
Post-turnover
Clinicians did not reconsider diagnosis of UTI with mental status change
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - reduced hospital admissions is the use of teams of nurse practitioners (NPs) (or physician assistants … [PAs])
and physicians in managing SNF patients.(13) Such teams often have more time dedicated to the … These fundamental
staffing principles are necessary but not sufficient to change behavior and improve … Teams of physicians and nurse practitioners (or physician assistants) can be highly effective in
managing … Early
learnings have led
to adoption of
cross-continuum
teams in other
states and regions
as well
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - RW: How does the digitization of a health care work environment change the kinds of issues that we've … Change the ability to improve care, improve safety, and improve quality? … The effect of that system change is to reimagine even what the work is. … , between teams
and teams. … change.