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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - systems conducted their own internal efforts, and all 220 California hospitals were exposed to state-wide … Safety assessment of a large-scale improvement collaborative to reduce nulliparous cesarean delivery … Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery … Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery … Labor and Delivery
Health Care Providers
Physicians
Nurses
View More
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - Nonetheless, the take-home message is that systems of safety did not endure and that we need to recommit … The last thing I want to mention is establishing the systems of safety and those key tools of high-reliability … , the shift to digital measures has facilitated real-time assessment of the quality of care being provided … Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). … Topic
Researchers
General Public
Hospitals
Ambulatory Care
Health Care Providers
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - medication safety
assessment, as well as an assessment of environmental, functional and psychosocial … (e.g., medication dispensing and reminder systems). … Consumer-oriented materials that
explain the program are available from Partners in Care. … payment by medical groups, health systems, and health plans. … Evaluation of a pharmacist-led
medication assessment used to identify prevalence of and associations
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - before transfusion, two people verify the ABO group of the
recipient and the donor ABO group and confirm … Therefore, risk assessment is difficult due to underreporting and the fact that
there is no centralized … performance of instrument maintenance and
function checks; (5) assessment of test performance through … testing of samples; and (6) assessment of problem-
solving skills.21 A monitoring process, typically … Implementing strong systems processes as discussed in this Commentary should reduce the
risk of errors
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - , are making machines and systems more and more intelligent, to take over more and more of the load from … And the automatic systems will not cope. … DN: What we need is systems thinking, first of all, and second, integrated displays that capture a large … care providers, I have found that the concepts of human factors engineering often inspire two types … Cognitive and usability engineering methods for the evaluation of clinical information systems.
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psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - in health care providers who report that they have had education in this area.7
Anchoring bias, or … ) when making decisions heavily influences health care providers as they go about
their daily work. … structure of
the handoff is adaptable to other health care providers and situations. 13
When clinicians … With the development of EHR, more clerical and administrative tasks fall on all healthcare
providers … Now more than ever, as the demands on healthcare workers reach new peaks and continue to change
day-to-day
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psnet.ahrq.gov/periodic-issue/periodic-issue-395
June 28, 2023 - The winners of the competition are University of Missouri, University of Chicago Medicine and Chesapeake … Most of the studies focused on decreasing risk of falls and/or medication errors, mostly in the home … and the effect of debiasing strategies. … The winners of the competition are University of Missouri, University of Chicago Medicine and Chesapeake … Soon after the end of the procedure, the patient complained of severe chest pain and echocardiographic
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - physicians other than those primarily responsible, and the limitations of "signout," the transfer of … Without a complete history, a physical exam, and a full assessment of a patient's problems, providing … signout database systems are two examples of relatively simple, inexpensive interventions that can improve … signouts and cross-coverage while more expensive and complex systems are being implemented. … Topic
Hospitals
Health Care Providers
Information Professionals
Medicine
Nurse Care
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psnet.ahrq.gov/issue/fatal-case-iatrogenic-hypercalcemia-after-calcium-channel-blocker-overdose
October 26, 2022 - in healthcare workers during the Covid-19 pandemic: a multinational cross-sectional study. … systems. … assessment of success factors. … July 25, 2012
Rapid response systems: identification and management of the "prearrest … of Learning Healthcare Systems.
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Their
2002 statement eliminated the phrase “at the end of life.”15 This insightful assessment and the … this case).10 These systems-based interventions helped
to upstream palliative care and “palliate” the … Proactive Psychosocial Assessment and Care
Although licensed clinical social workers are integral to … Referrals for psychosocial assessment and care planning can assist patients and
families in dealing … with the impact of diagnosis and treatment on their lives and ability to access care.19
Routine assessment
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - signs of metastases to the liver and bone, as well as multiple small fractures of the pelvic girdle. … Regulatory bodies, health systems, and professional societies have all encouraged providers to taper … Finally, all healthcare delivery systems should have systems in place to ensure that all patients receive … Although pain management specialists are not available in all health systems and communities, this PCP … Topic
Ambulatory Clinic or Office
Health Care Providers
Anesthesiology
Primary Care
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - , Breathing, Circulation, Disability, and Exposure (ABCDE) assessment of the front and
back of the patient … Adjuncts such as chest x-ray (CXR), pelvis x-ray, and/or the Focused Assessment with
Sonography in Trauma … (MTP) in a trauma patient.3 In most scoring systems,
hypotension is prioritized, as is evidence of … Most scoring systems consider the activation of MTP, combined with
other laboratory values and vital … Accuracy of Focused Assessment with Sonography for Trauma (FAST)
in blunt abdominal trauma.
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - of open and clear communication in transitions of care for patient safety
The Case
Patient … injury with subsequent abscess of his right knee and osteomyelitis of the distal femur requiring bone … Education of the patient is very important and is provided by the infusion company. … or dextrose before and after administration of the medication. … OPAT has been successfully utilized by health systems since the 1970s.
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - procedures and systems that recognize the frailties of normal human cognition. … The role of mental models in team performance in complex systems. … IEEE Transactions on Systems, Man, and Cybernetics. 1992;22:1296-1308. [ go to related site ]
Figure … March 10, 2011
Surgical crisis management skills training and assessment: a stimulation-based … Topic
Operating Room
Health Care Providers
Quality and Safety Professionals
Geriatrics
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - There are systems that are RFID-linked, recognizing the time and exact amount of product used at the … Other systems monitor the gestures of the health care workers, or the amount of time and where and when … It is something that patients have a right to expect and that once the systems are in place and the education … Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. … Automated measures of hand hygiene compliance among healthcare workers using ultrasound: validation and
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - David Meltzer, Chief of the Section of Hospital Medicine and Director of the Center for Health and Social … Finally, growing pressures to improve quality and safety created a new paradigm which emphasized systems … Far from being a threat to the hospitalist model, I can easily see health systems embracing a hybrid … For the better care part of it, we used HCAHPS [Hospital Consumer Assessment of Healthcare Providers … and Systems] scores to measure patient experience.
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psnet.ahrq.gov/issue/diagnostic-errors-medicine-case-neglect
July 15, 2015 - A review of evidence, practice and consumer perspectives. … March 16, 2011
A systems approach to morbidity and mortality conference. … December 13, 2023
Complexity and challenges of the clinical diagnosis and management … April 12, 2023
Assessment of potentially inappropriate prescribing of opioid analgesics … July 6, 2022
Improving medical residents’ self-assessment of their diagnostic accuracy
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - of systems and human actions … Use of simulation to test systems and prepare staff for a new hospital transition. … Weinger is Director of the Center for Research and Innovation in Systems Safety and Professor of Anesthesiology … Also, in terms of general clinical competence, one could see ongoing assessment of practitioners along … about modifying systems, what level of the system?
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - , and quality measures whereby a consumer can compare one place to another. … should move from quality assessment to a performance improvement mode, operating more along the lines … systems with sophisticated clinical decision support systems that incorporate relevant clinical information … .( 13 ) Structured communication strategies, including the use of SBAR ("Situation, Background, Assessment … exclusive of efforts to improve communication between health care providers, may have only limited benefits
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - Describe the importance of weight-based dosing of medications and fluids in pediatrics. … The night nurse communicated the minimal intake of fluids and poor urine output to the day nurse at the … the inability of children
to communicate with health care providers (in this case, a patient who is … In this case,
the institutional expectation and standard of care should have been assessment and reporting … Tools to assist in managing children, such as computerized bedside management systems (that can
both