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Showing results for "the change teams".

2201. A tragic death: a time to blame or a time to learn? | PSNet
      psnet.ahrq.gov/issue/tragic-death-time-blame-or-time-learn
      March 23, 2011 - View more articles from the same authors. … Same Author(s) Towards safer, better healthcare: harnessing the natural properties of … March 23, 2011 Surgical teams' attitudes about surgical safety and the surgical safety … March 7, 2012 Culture, language, and patient safety: making the link. … June 25, 2010 The safety of Australian healthcare: 10 years after QAHCS.

2202. Human factors in patient safety as an innovation. | PSNet
      psnet.ahrq.gov/issue/human-factors-patient-safety-innovation
      June 09, 2021 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … September 11, 2019 Usability of a human factors-based clinical decision support in the … July 31, 2019 Blind spots in the science of safety. … July 16, 2014 The science of human factors: separating fact from fiction.

2203. Electronic data collection using MedWatchPlus portal and rational questionnaire. | PSNet
      psnet.ahrq.gov/issue/electronic-data-collection-using-medwatchplus-portal-and-rational-questionnaire
      July 03, 2013 - The comment collection period is now closed. … Copy Citation Related Resources From the Same Author(s) Patient Safety and … October 16, 2013 Agency information collection activities: Assessing the Impact of the … October 3, 2017 MedWatch: The FDA Safety Information and Adverse Event Reporting Program … September 30, 2015 View More See More About The Topic Policy Makers

2204. Safety of anesthetic and perioperative medication practices. | PSNet
      psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices
      January 14, 2019 - Medication use in the surgical environment is complex and high-risk . … This article describes steps toward the implementation of medication safety process improvement programs … for the operating room . … January 14, 2019 Variation in the reporting of elective surgeries and its influence on … October 7, 2020 The physiology of failure: identifying risk factors for mortality in

2205. Actively caring for safety: overcoming bystander apathy. | PSNet
      psnet.ahrq.gov/issue/actively-caring-safety-overcoming-bystander-apathy
      December 03, 2014 - The aim is to better report problems and change situations that threaten patient safety. … May 7, 2018 Order scanning systems may pull multiple pages through the scanner at the … hospital to the community. … June 10, 2018 Side tracks on the safety express. … eye of the beholder.

2206. 'America's other drug problem': copious prescriptions for hospitalized elderly. | PSNet
      psnet.ahrq.gov/issue/americas-other-drug-problem-copious-prescriptions-hospitalized-elderly
      May 12, 2021 - View more articles from the same authors. … WebM&M commentary discussed strategies to safely manage medications in older patients and highlighted the … Copy Citation Related Resources From the Same Author(s) Addiction treatment … August 17, 2022 Skin cancer is a risk no matter the skin tone. … June 25, 2014 Patients taking their own medications while in the hospital.

2207. The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary Report. | PSNet
      psnet.ahrq.gov/issue/pennsylvania-learning-exchange-helping-states-improve-and-integrate-patient-safety
      July 08, 2015 - Meeting/Conference Proceedings The Pennsylvania Learning Exchange: Helping States … Citation Text: The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety … View more articles from the same authors. … April 3, 2019 "To Err Is Human" Report Retrospective and the Decade Ahead. … September 10, 2008 Report on the Medical Insurance Feasibility Study.

2208. AHRQ Safety Program for Improving Antibiotic Use. | PSNet
      psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use
      December 24, 2008 - This project used the Comprehensive Unit-based Safety Program improvement strategy to develop and test … a bundle of interventions in the ambulatory care , long-term care , and acute care environments. … The final cohort concluded in November 2020. … April 28, 2021 Assessment of changes in visits and antibiotic prescribing during the … August 16, 2017 An improvement approach to integrate teaching teams in the reporting

2209. Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive. | PSNet
      psnet.ahrq.gov/issue/right-kind-wrong-why-learning-fail-can-teach-us-thrive
      February 06, 2018 - View more articles from the same authors. … Despite the harm that failure can cause, its value as a learning opportunity , if examined through the … February 6, 2018 The Checklist Manifesto: How to Get Things Right. … January 13, 2010 The Fearless Organization: Creating Psychological Safety in the Workplace … May 16, 2012 How to master the new art of training: teamwork on the fly.

2210. A Framework for Safe, Reliable, and Effective Care. | PSNet
      psnet.ahrq.gov/issue/framework-safe-reliable-and-effective-care
      January 27, 2016 - View more articles from the same authors. … The authors emphasize the importance of engaging patients and their families as members of the care … February 25, 2013 Improving the Reliability of Health Care. … July 12, 2017 Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. … August 2, 2017 Changing the narratives for patient safety.

2211. Oxford Professional Practice: Handbook of Patient Safety. | PSNet
      psnet.ahrq.gov/issue/oxford-professional-practice-handbook-patient-safety
      June 16, 2012 - This publication introduces the foundations of patient safety. … June 15, 2022 The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making … January 27, 2021 Artificial Intelligence in Health Care: The Hope, the Hype, the Promise … , the Peril. … : a prospectus for change toward racial justice in medical education and health sciences research: REPAIR

2212. An interview with Audrey Nelson. Interviewed by Steven Berman. | PSNet
      psnet.ahrq.gov/issue/interview-audrey-nelson-interviewed-steven-berman
      January 19, 2022 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … Same Author(s) Psychometric properties of the perinatal missed care survey and missed … April 12, 2023 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … January 29, 2020 Changing the "working while sick" culture.

2213. U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument | PSNet
      psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
      February 26, 2025 - 0.72). 3 The project team made minor revisions to the original tool to address feedback from the pilot … Since the release of the revised iteration of the tool (i.e., the Revised Safer Dx Instrument), use of … To effectively use the tool, the implementing teams need logistical support and resources, such as available … episode, reviewers have the option to conduct a process evaluation to determine the root cause of the … To effectively use the tool, the implementing teams need logistical support and resources, such as available

2214. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50615/psn-pdf
      October 30, 2019 - Multiple phone calls ensued between the operating room nursing staff and the emergency department, the … blood bank, the surgeons and, ultimately the OR nurse was able to  confirm the correct identity and … In the era of physical charts, John Doe-related confusion would end at the level of the chart. … using the phonetic alphabet according to the stage of the current name cycle and a date. … identities in the EHR and effectively became “new” patients in the eyes of the EHR and the staff.

2215. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33790/psn-pdf
      August 01, 2015 - In current systems, abnormal findings and change in a patient's status are easily missed during the … discharge process, despite the fact that the information is contained somewhere in the EHR, just not … This process of supporting the cognitive needs of the user in health care is further complicated by the … complexities of the implementation process and the design decisions required of the implementing provider … intersection between the technology and the users and design the system accordingly.

2216. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
      October 01, 2011 - presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http:/ … As the patient was transferred out of the ICU, a physical therapist (PT) was consulted to assist in the … In reviewing the medical records, the PT noted the initial shoulder injury on admission. … with mean arterial pressure less than 65 mm Hg New administration of pressor or antiarrhythmic agent Change … patients in the ICU.

2217. Introducing the Redesigned AHRQ Patient Safety Network | PSNet
      psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
      December 01, 2005 - The Agency for Healthcare Research and Quality (AHRQ), under the leadership of the late Dr. … the release of the IOM report. … from the epidemiology of adverse events to the benefits of barcoding to best practices in the use of … In an editorial I wrote at the time of PSNet's launch ( 2 ), I reflected on the breadth of the field, … September 1, 2011 Perspective Organizational Change

2218. Never Events | PSNet
      psnet.ahrq.gov/primer/never-events
      June 15, 2024 - The NQF's Never Events are also considered sentinel events by the Joint Commission. … and apologize to the patient, report the event, and waive all costs associated with the event. … the quality of care. … July 24, 2024 Identifying a list of healthcare 'never events' to effect system change: a systematic … October 25, 2023 Identifying a list of healthcare 'never events' to effect system change

2219. EMR Entry Error: Not So Benign | PSNet
      psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
      July 01, 2012 - Three days later, the intern on the team was reviewing the patient's clinical information in the hospital's … The team and the primary care doctor all met with the patient to disclose the mistake, but clearly the … In fact, when called and asked if they had seen the error in X (the name of the EMR), the pathologist … As implementations and updates proceed in parallel, software and work processes change in ways that create … That the medical team found the error is perhaps the most encouraging part of this case.

2220. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865455/psn-pdf
      March 27, 2024 - care and the patient’s readmission to the hospital. … shown to strengthen resilience, improve teamwork, and reduce risk of adverse events among healthcare teams … care teams. … I-PASS and TeamSTEPPS, can foster a culture of safety and improve communication skills among healthcare teams … The Joint Commission. Sentinel Event Data 2022 Annual Review. The Joint Commission; 2023.