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psnet.ahrq.gov/issue/leadership-strategies-medical-school-deans-promote-quality-and-safety
August 10, 2022 - View more articles from the same authors. … The author shares findings from interviews with 10 medical school deans regarding the strategies they … August 10, 2022
The 5th National Audit Project (NAP5) on accidental awareness during … January 11, 2023
The REPAIR Project: a prospectus for change toward racial justice in … May 9, 2018
The use of simulation in emergency medicine: a research agenda.
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psnet.ahrq.gov/issue/those-found-responsible-have-been-sacked-some-observations-usefulness-error
September 28, 2010 - View more articles from the same authors. … as an approach to determine the foci of how failure occurs. … This commentary summarizes challenges to the use of the term “ human error ” while considering its usefulness … first 2 years of the COVID-19 pandemic. … May 17, 2017
The Critical Care Safety Study: the incidence and nature of adverse events
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psnet.ahrq.gov/issue/whom-bell-commission-tolls-unintended-effects-limiting-residents-hours
April 20, 2011 - View more articles from the same authors. … The author debates the viability of the Institute of Medicine residency training reforms noted in their … testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams … November 26, 2014
The new recommendations on duty hours from the ACGME Task Force. … October 31, 2011
The response of the APPD, CoPS and AAP to the Institute of Medicine
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psnet.ahrq.gov/issue/how-do-simulated-error-experiences-impact-attitudes-related-error-prevention
October 19, 2022 - View more articles from the same authors. … Growing evidence supports the use of simulation training as a powerful tool in medical education. … to the risk of error. … A systematic review of the literature. … team situation awareness in the OR.
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psnet.ahrq.gov/issue/perceived-adverse-patient-outcomes-correlated-nurses-workload-medical-and-surgical-wards
February 01, 2013 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS
Download Citation
Related Resources From the … November 4, 2020
The impact of pharmacists-led medicines reconciliation on healthcare … patients admitted through the emergency department. … March 31, 2010
The content and context of change of shift report on medical and surgical
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psnet.ahrq.gov/issue/mental-models-basic-concept-human-factors-design-infection-prevention
April 26, 2017 - December 27, 2018
Hand hygiene and healthcare system change within multi-modal promotion … June 21, 2023
Can aviation-based team training elicit sustainable behavioral change? … March 11, 2015
COVID-19: the dark side and the sunny side for patient safety. … October 14, 2020
Supporting the emotional well-being of health care workers during the … August 5, 2020
The rising frequency of IT blackouts indicates the increasing relevance
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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.