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Showing results for "the change teams".

  1. Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. | PSNet

    psnet.ahrq.gov/issue/sustained-improvement-quality-patient-handoffs-after-orthopaedic-surgery-i-pass-intervention
    June 15, 2022 - In this study, researchers modified the I-PASS tool for use in orthopedic surgery and assessed the impact … After 18 months, there was sustained adherence to the tool and the quality of handoffs improved, but … February 12, 2020 A systematic review of the effect of telepharmacy services in the community … June 30, 2021 Dedicated teams to optimize quality and safety of surgery: a systematic … August 9, 2013 Handoff checklists improve the reliability of patient handoffs in the

  2. Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. | PSNet

    psnet.ahrq.gov/issue/effects-workload-work-complexity-and-repeated-alerts-alert-fatigue-clinical-decision-support
    March 04, 2015 - The authors recommend reducing the number of alerts per patient to address alarm fatigue. … Same Author(s) The Triangle Model for evaluating the effect of health information technology … Tool for Improving Patient Safety March 29, 2023 How real-time data can change … the patient safety game. … in the inpatient setting.

  3. Intensive care medicine in 2050: preventing harm. | PSNet

    psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm
    November 25, 2020 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … August 20, 2018 Magnitude and modifiers of the weekend effect in hospital admissions: … August 21, 2013 Findings of the first consensus conference on medical emergency teams … November 29, 2023 The practice of respect in the ICU.

  4. Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. | PSNet

    psnet.ahrq.gov/issue/deficiencies-emergent-and-outpatient-care-patient-alcohol-use-disorder-richard-l-roudebush-va
    July 13, 2022 - Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the … of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona. … Emergency at the VA Southern Nevada Health Care System in Las Vegas. … John Cochran Division of the VA St. … April 12, 2023 Care Delivery within Community Mental Health Teams.

  5. Four-year impact of an alert notification system on closed-loop communication of critical test results. | PSNet

    psnet.ahrq.gov/issue/four-year-impact-alert-notification-system-closed-loop-communication-critical-test-results
    June 21, 2016 - View more articles from the same authors. … The communication of critical test results is a National Patient Safety Goal . … The introduction of the system led to better closed-loop communication and appropriate documentation. … June 21, 2016 An initiative to improve the management of clinically significant test … December 19, 2018 Unscheduled radiologic examination orders in the electronic health

  6. Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers. | PSNet

    psnet.ahrq.gov/issue/women-large-vessel-occlusion-acute-ischemic-stroke-are-less-likely-be-routed-comprehensive
    October 12, 2022 - View more articles from the same authors. … Same Author(s) The Lancet Commission on lessons for the future from the COVID-19 pandemic … December 4, 2016 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … November 11, 2020 Guidance for health care leaders during the recovery stage of the COVID … August 9, 2023 Diagnostic accuracy of physician-staffed emergency medical teams: a retrospective

  7. CT for suspected appendicitis in children: an analysis of diagnostic errors. | PSNet

    psnet.ahrq.gov/issue/ct-suspected-appendicitis-children-analysis-diagnostic-errors
    August 20, 2018 - View more articles from the same authors. … The authors suggest that the gold standard of diagnosis lies in the pathological findings, which should … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … July 25, 2011 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams

  8. Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? | PSNet

    psnet.ahrq.gov/issue/incident-reporting-systems-what-will-it-take-make-them-less-frustrating-and-achieve-anything
    November 03, 2021 - View more articles from the same authors. … This commentary challenges the viability of the concept in healthcare, examines barriers to its success … Same Author(s) Looking back on the history of patient safety: an opportunity to reflect … June 6, 2018 Using participatory design to engage physicians in the development of a … January 23, 2017 Electronic approaches to making sense of the text in the adverse event

  9. Why Things Bite Back: Technology and the Revenge of Unintended Consequences. | PSNet

    psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
    March 20, 2019 - What interests Tenner, however, are “revenge effects,” which he defines as the exact opposite of the … It is this feature of the laparoscopic procedure that resulted in a significant increase in the number … March 20, 2019 Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change … Health Care from the Inside Out. … July 5, 2016 The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer

  10. Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States. | PSNet

    psnet.ahrq.gov/issue/hospital-acquired-conditions-reduction-program-racial-and-ethnic-diversity-and-magnet
    June 08, 2022 - Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the … Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the … View more articles from the same authors. … December 21, 2017 The Psychological Safety Scale of the Safety, Communication, Operational … April 13, 2022 Cost of health care-associated infections in the United States.

  11. A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. | PSNet

    psnet.ahrq.gov/issue/comprehensive-quality-assurance-program-personnel-and-procedures-radiation-oncology-value
    November 18, 2020 - View more articles from the same authors. … that included a voluntary error reporting system and structured checklists significantly reduced the … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … August 26, 2020 The fusion of incident learning and failure mode and effects analysis … December 18, 2014 The effect of an organizational network for patient safety on safety

  12. Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study. | PSNet

    psnet.ahrq.gov/issue/potential-costs-and-consequences-associated-medication-error-hospital-discharge-expert
    September 05, 2018 - View more articles from the same authors. … on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … March 14, 2022 From the flight deck to the operating room: an initial pilot study of … December 12, 2023 Cost of health care-associated infections in the United States.

  13. Medication safety incidents associated with the remote delivery of primary care: a rapid review. | PSNet

    psnet.ahrq.gov/issue/medication-safety-incidents-associated-remote-delivery-primary-care-rapid-review
    June 29, 2022 - Review Medication safety incidents associated with the remote delivery of primary … View more articles from the same authors. … the COVID-19 pandemic. … with remote delivery of primary care prior to the pandemic. … perspectives during the COVID-19 pandemic.

  14. Overestimation of clinical diagnostic performance caused by low necropsy rates. | PSNet

    psnet.ahrq.gov/issue/overestimation-clinical-diagnostic-performance-caused-low-necropsy-rates
    February 09, 2011 - View more articles from the same authors. … All of these findings fall significantly below the previously reported rates. … September 20, 2011 The vanishing nonforensic autopsy. … July 3, 2013 Expanding the scope of Critical Care Rapid Response Teams: a feasible approach … January 14, 2011 The "Big Dog" effect: variability assessing the causes of error in diagnoses

  15. The effect of a clinical decision support for pending laboratory results at emergency department discharge. | PSNet

    psnet.ahrq.gov/issue/effect-clinical-decision-support-pending-laboratory-results-emergency-department-discharge
    April 24, 2018 - Study The effect of a clinical decision support for pending laboratory results at … The Effect of a Clinical Decision Support for Pending Laboratory Results at Emergency Department Discharge … View more articles from the same authors. … to respond "yes" or "no" regarding whether tests were pending at the time of discharge from the emergency … patients with tests pending increased following the intervention, contrary to intentions.

  16. Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles. | PSNet

    psnet.ahrq.gov/issue/crossing-academic-boundaries-diagnostic-safety-10-complex-challenges-and-potential-solutions
    November 30, 2022 - The authors of this article apply high-reliability organization principles to the National Academy … The goal was to identify diagnostic challenges as well as strategies and solutions that diagnostic teams … November 30, 2022 COVID-19: the dark side and the sunny side for patient safety. … July 6, 2022 The Psychological Safety Scale of the Safety, Communication, Operational … July 1, 2020 Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health

  17. Factors influencing the reporting of medication errors and near misses among nurses: a systematic mixed methods review. | PSNet

    psnet.ahrq.gov/issue/factors-influencing-reporting-medication-errors-and-near-misses-among-nurses-systematic-mixed
    April 23, 2014 - View more articles from the same authors. … The main factor contributing to decision-to-report is the expected reaction of superiors, colleagues … safe use of insulin in the hospital setting. … context of a professional accountability culture change program: a qualitative analysis. … quality of care: a review of the research literature.

  18. Sepsis alert systems, mortality, and adherence in emergency departments: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/sepsis-alert-systems-mortality-and-adherence-emergency-departments-systematic-review-and-meta
    September 06, 2017 - View more articles from the same authors. … This systematic review included 22 studies and examined the use of sepsis alert systems in the Emergency … The researchers found that sepsis alert systems were associated with reduced risk of mortality and decreased … 7 XML Endnote tagged PubMedId RIS Download Citation Related Resources From the … October 21, 2020 National study on the frequency, types, causes, and consequences of

  19. Should medical errors be disclosed to pediatric patients? Pediatricians' attitudes toward error disclosure. | PSNet

    psnet.ahrq.gov/issue/should-medical-errors-be-disclosed-pediatric-patients-pediatricians-attitudes-toward-error
    June 15, 2011 - View more articles from the same authors. … The practice of disclosing errors to patients is considered the standard of care, but many physicians … March 30, 2022 Safer paediatric surgical teams: a 5-year evaluation of crew resource … March 20, 2019 Tolerating uncertainty—the next medical revolution? … February 17, 2017 In support of the medical apology: the nonlegal arguments.

  20. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. | PSNet

    psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review
    September 15, 2021 - Analysis of a case and review of the literature. … Analysis of a case and review of the literature. … View more articles from the same authors. … Analysis of a case and review of the literature. … February 8, 2023 Shift change handovers and subsequent interruptions: potential impacts
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