Communication complexity/dissemination IT/information needs Program management Resource management Service structure Service area issues Team size and makeup Team skill and stability We consider the inherent risk of the process for…
Fig. 18.1 EPIS framework illustrating outer and inner context, linkages, EBP fit, and intervention developer Fig. 18.2 Exploration, Preparation, Implementation, Sustainment (EPIS) Framework illustrating the four implementation phases and outer…
Fig. 16.1 An architectural diagram of the relationship between clinical care information systems and clinical research systems and registries as part of the ECIS paradigm IA-CIS do not solve the…
Fig. 48.1 Per Capital Health Care Spending since 1980 by country [1] As the harsh realities of financial catastrophe associated with out-of-control health care costs/spending became accepted as inevitable by…
Major VTE risk factors • Malignancy • Personal history of previous VTE • Family history of VTE • Prolonged surgical procedure (>2 h) • Major general surgery • Major traumatic injury • Hip or leg fracture • Hip…
Safety Freedom from accidental injuries Error The failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve…
Fig. 39.1 RCA time line of event The second meeting to ascertain why the event occurred never happened as Kelly’s self-assignment of blame was accepted as the root cause. Table…
Fig. 36.1 Transitions across surgical care. Figure reprinted with permission from the American Society of Anesthesiologists (asahq.org/psh) Each transition of care, from one phase in the surgical pathway to another,…
Fig. 14.1 % Positive responses over time by MSWBI question (composite of all classes). Percentage (vertical axis) of positive (“yes”) responses to each MSWBI question for all students grouped by…
Fig. 26.1 Comprehensive Surgical Checklist. Reprinted with permission from AORN.org. Copyright © 2016, AORN, Inc.: Denver, CO. All rights reserved In particular, interventions to prevent or reduce never events include:…
