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Showing results for "veterans affairs".

81. Critical Deficiencies at the Washington DC VA Medical Center. | PSNet
    psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center
    December 16, 2020 - Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. … Affairs, Office of Inspector General. … Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures . … Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. … Crisis Line Response to a Veteran Caller Who Died.

82. Incidence- versus prevalence-based measures of inappropriate prescribing in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/incidence-versus-prevalence-based-measures-inappropriate-prescribing-veterans-health
    March 18, 2020 - This health system performance study ranked sites within the Veterans Affairs health system using … two measures of potentially inappropriate prescribing in older veterans. … Affairs: a multi-state qualitative study. … Affairs. … Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran

83. Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. | PSNet
    psnet.ahrq.gov/issue/patient-suicide-locked-mental-health-unit-west-palm-beach-va-medical-center-florida
    January 24, 2024 - Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. … Affairs, Office of Inspector General. … This report describes an investigation into a patient suicide incident in the Veterans Affairs health … Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. … Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans

84. The State of VA Health Care. | PSNet
    psnet.ahrq.gov/issue/state-va-health-care
    May 01, 2015 - Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014 … ' Affairs United States Senate. 113th Cong (September 9, 2014). … In this hearing Veterans Affairs leadership provide an update on the current investigation into data … Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014 … Affairs.

85. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45972/psn-pdf
    April 05, 2017 - Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing … homes and non–Veterans Affairs nursing homes. … Comparing Catheter-Associated Urinary Tract Infection Prevention Programs Between Veterans Affairs Nursing … Homes and Non-Veterans Affairs Nursing Homes. … Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating

86. Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans. | PSNet
    psnet.ahrq.gov/issue/impact-opioid-safety-initiative-opioid-related-prescribing-veterans
    February 10, 2021 - Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans. … This intervention at Veterans Affairs medical centers used an electronic dashboard to provide feedback … Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran … Affairs. … Affairs prevention initiative.

87. Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids | PSNet
    psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
    October 30, 2024 - Department of Veterans Affairs (VA) study of nearly 124,000 veterans, those receiving the highest doses … Department of Veterans Affairs, Veterans Health Administration, Pharmacy Benefits Management Academic … Department of Veterans Affairs (VA), U.S. Department of Defense (DoD). … Office of Mental Health and Suicide Prevention, US Dept of Veterans Affairs; 2021. … Department of Veterans Affairs (VA), U.S. Department of Defense (DoD).

88. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34802/psn-pdf
    January 01, 2016 - The Veterans Affairs root cause analysis system in action. … The Veterans Affairs Root Cause Analysis System in Action. … https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action This article focuses … Affairs (VA) facilities in the RCA process. … https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action https://psnet.ahrq.gov

89. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/35462/psn-pdf
    February 18, 2011 - Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. … Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. … https://psnet.ahrq.gov/issue/effect-transformation-veterans-affairs-health-care-system-quality-care … Findings illustrated significant improvements over time for all indicators within the Veterans Affairs … https://psnet.ahrq.gov/issue/effect-transformation-veterans-affairs-health-care-system-quality-care https

90. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60713/psn-pdf
    July 22, 2020 - Assessment of health information technology-related outpatient diagnostic delays in the US Veterans … Affairs health care system: a qualitative study of aggregated root cause analysis data. … Assessment of health information technology-related outpatient diagnostic delays in the US Veterans … Affairs health care system: a qualitative study of aggregated root cause analysis data. … Using root cause analysis data submitted to the Veterans Affairs (VA) National Center for Patient Safety

91. Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/lessons-learned-building-culture-patient-safety-within-veterans-health-administration
    November 06, 2019 - Building a Culture of Patient Safety Within the Veterans Health Administration. … Building a Culture of Patient Safety Within the Veterans Health Administration. … US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. … ' Affairs Subcommittee on Health.  117th Cong. 1 st Sess (2021). … US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.

92. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. | PSNet
    psnet.ahrq.gov/issue/disclosing-large-scale-adverse-events-us-veterans-health-administration-lessons-media
    August 18, 2021 - Study Disclosing large scale adverse events in the US Veterans Health Administration … Affairs health system, media reports did not convey specific aspects of error disclosure , such as … Affairs leadership, policymaker, research and stakeholder partnership. … Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran … Affairs prevention initiative.

93. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet
    psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
    October 12, 2022 - Book/Report Evaluation of Quality, Safety and Value in Veterans Health Administration … Citation Text: Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities … Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03. … Affairs Office of Inspector General; 2022. … Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

94. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45851/psn-pdf
    February 22, 2017 - decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans … Affairs prevention initiative. … Affairs prevention initiative. … Researchers attribute these results to implementation of the Veterans Affairs MRSA Prevention Initiative … psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus https://psnet.ahrq.gov/issue/veterans-affairs-initiative-prevent-methicillin-resistant-staphylococcus-aureus-infections

95. Disclosure of Adverse Events to Patients. | PSNet
    psnet.ahrq.gov/issue/disclosure-adverse-events-patients
    November 29, 2023 - Department of Veterans Affairs, Washington DC: Veterans Health Administration; October 31, 2018. … Facebook Twitter Linkedin Copy URL May 4, 2015 Department of Veterans … Affairs, Washington DC: Veterans Health Administration; October 31, 2018. … This Veterans Health Administration (VHA) directive provides direction for disclosing medical mistakes … Department of Veterans Affairs, Washington DC: Veterans Health Administration; October 31, 2018.

96. Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. | PSNet
    psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis
    May 04, 2022 - August 11, 2021 Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals … Affairs root cause analysis system. … September 19, 2016 Department of Veterans Affairs Chief Resident in Quality and Patient … through Department of Veterans Affairs-contracted community care. … February 21, 2018 Inpatient suicide and suicide attempts in Veterans Affairs hospitals

97. Awareness and use of a cognitive aid for anesthesiology. | PSNet
    psnet.ahrq.gov/issue/awareness-and-use-cognitive-aid-anesthesiology
    January 05, 2017 - January 5, 2017 Inpatient suicide and suicide attempts in Veterans Affairs hospitals. … April 30, 2014 A checklist to identify inpatient suicide hazards in Veterans Affairs … Affairs (VA) system. … Affairs. … Affairs hospitals.

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37546/psn-pdf
    June 14, 2011 - Effective interventions and implementation strategies to reduce adverse drug events in the Veterans … Affairs (VA) system. … Effective interventions and implementation strategies to reduce adverse drug events in the Veterans … Affairs (VA) system. … https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action https://psnet.ahrq.gov

99. Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. | PSNet
    psnet.ahrq.gov/issue/improving-administration-and-documentation-enteral-nutrition-support-therapy-veteran-affairs
    September 09, 2020 - Improving administration and documentation of enteral nutrition support therapy in a Veteran … Affairs health care system: use of medication administration record and bar code scanning technology … Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs … Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs

100. The effectiveness of root cause analysis: what does the literature tell us? | PSNet
     psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what-does-literature-tell-us
     February 11, 2013 - Affairs medical centers. … April 24, 2011 Code debriefing from the Department of Veterans Affairs (VA) Medical Team … September 19, 2016 A checklist to identify inpatient suicide hazards in Veterans Affairs … Afghanistan conflicts: review of case reports from a national Veterans Affairs database. … A systematic review at the Department of Veterans Affairs.