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Showing results for "adverse event".
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361. No pay for "never event" errors becoming standard. | PSNet
     psnet.ahrq.gov/issue/no-pay-never-event-errors-becoming-standard
     March 07, 2012 - Newspaper/Magazine Article No pay for "never event" errors becoming standard. … Citation Text: No pay for "never event" errors becoming standard. O'Reilly KB. … Copy URL Cite Citation Citation Text: No pay for "never event … March 11, 2009 Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries … February 18, 2009 Adverse Events in Hospitals: Overview of Key Issues.

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60580/psn-pdf
     January 01, 2022 - gains: a 7-year follow-through of a hospital-wide patient safety improvement project on hospital-wide adverse … event outcomes and patient safety culture. … event outcomes and patient safety culture. … Over a 7-year period, adverse event rates decreased significantly (as did the incidence of preventable … adverse events and the incidence of events resulting in permanent harm, the use of life-sustaining

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60033/psn-pdf
     March 11, 2020 - Interventions to reduce adverse drug event-related outcomes in older adults: a systematic review and … Interventions to Reduce Adverse Drug Event-Related Outcomes in Older Adults: A Systematic Review and … https://psnet.ahrq.gov/issue/interventions-reduce-adverse-drug-event-related-outcomes-older-adults- … https://psnet.ahrq.gov/issue/interventions-reduce-adverse-drug-event-related-outcomes-older-adults-systematic-review-and … https://psnet.ahrq.gov/issue/interventions-reduce-adverse-drug-event-related-outcomes-older-adults-systematic-review-and

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40708/psn-pdf
     March 02, 2012 - Barriers to adverse event and error reporting in anesthesia. … Barriers to Adverse Event and Error Reporting in Anesthesia. … https://psnet.ahrq.gov/issue/barriers-adverse-event-and-error-reporting-anesthesia This survey found … anesthesiologists minimized the impact of attitudinal and emotional barriers on reporting unspecified adverse … https://psnet.ahrq.gov/issue/barriers-adverse-event-and-error-reporting-anesthesia https://psnet.ahrq.gov

365. Estimating hospital-related deaths due to medical error: a perspective from patient advocates. | PSNet
     psnet.ahrq.gov/issue/estimating-hospital-related-deaths-due-medical-error-perspective-patient-advocates
     November 08, 2023 - mortality, concerns about the studies, and the need for uniform adoption of safety standards to reduce adverse … December 21, 2016 Families as partners in hospital error and adverse event surveillance … May 9, 2018 Families as partners in hospital error and adverse event surveillance. … multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event … March 1, 2017 Electronic approaches to making sense of the text in the adverse event

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867523/psn-pdf
     January 15, 2025 - Ensuring sufficient patient notification efforts after a large-scale adverse event. … Ensuring sufficient patient notification efforts after a large-scale adverse event. … how-do-we-know-when-we-have-done-enough-ensuring-sufficient-patient- notification-efforts While large-scale adverse … This article provides an analytic framework for healthcare organizations to consider in the event of … look-back-and-talk-openly-responding-and-communicating-about-risk-large-scale-error-pathology https://psnet.ahrq.gov/issue/improving-healthcare-systems-disclosures-large-scale-adverse-events-department-veterans

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45938/psn-pdf
     September 29, 2017 - Is excessive resource utilization an adverse event? … Is Excessive Resource Utilization an Adverse Event? … https://psnet.ahrq.gov/issue/excessive-resource-utilization-adverse-event Overuse of therapies, medications … explores an incident involving medical overuse, discusses whether overuse should be assessed like adverse … https://psnet.ahrq.gov/issue/excessive-resource-utilization-adverse-event https://psnet.ahrq.gov/perspective

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866317/psn-pdf
     July 17, 2024 - bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses "Second victim syndrome" occurs when an adverse … event or error has a negative emotional impact on involved staff, including shame, depression, and … This article describes a debriefing tool for nurses who have just experienced an adverse event. … (Buoy/Break, Open-Up, Needs, Exit/Evaluate), is intended to be used as soon as possible after the event … bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45868/psn-pdf
     January 31, 2018 - Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events … Increasing Trainee Reporting of Adverse Events With Monthly Trainee- Directed Review of Adverse Events … medical students reported more errors after implementation of a monthly educational conference in which event … The authors conclude that trainee-led adverse event review conferences can increase event reporting. … https://psnet.ahrq.gov/issue/increasing-trainee-reporting-adverse-events-monthly-trainee-directed-review-adverse-events

370. Health care workers in the midst of crisis. | PSNet
     psnet.ahrq.gov/issue/health-care-workers-midst-crisis
     February 15, 2023 - Sentinel Event Alert. Feb 2, 2021;(62):1-7. … Sentinel Event Alert. Feb 2, 2021;(62):1-7. … March 18, 2020 Effect of Patient and Family Centered I-PASS on adverse event rates in … March 8, 2023 A review of adverse event reports from emergency departments in the Veterans … March 18, 2020 Electronic health record-based prediction models for in-hospital adverse

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846563/psn-pdf
     March 21, 2023 - event, healthcare workers involved in unanticipated adverse events are often traumatized by the event … Healthcare workers involved in a medical error or adverse event may experience a range of emotional … Healthcare staff involved in an adverse event can develop post-traumatic stress disorder (PTSD) with … The traumatic effects and negative feelings after involvement in an adverse event can also lead to professional … event.

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41964/psn-pdf
     April 17, 2013 - Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. … Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. … https://psnet.ahrq.gov/issue/use-hit-adverse-event-reporting-nursing-homes-barriers-and-facilitators … Few nursing homes surveyed used computerized methods to report errors or to monitor adverse event data … https://psnet.ahrq.gov/issue/use-hit-adverse-event-reporting-nursing-homes-barriers-and-facilitators

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45289/psn-pdf
     May 03, 2017 - Measuring harm in health care: optimizing adverse event review. … Measuring Harm in Health Care: Optimizing Adverse Event Review. … https://psnet.ahrq.gov/issue/measuring-harm-health-care-optimizing-adverse-event-review Determining … Investigators asked physicians, nurses, and pharmacists to rate the severity of harm for specific adverse … https://psnet.ahrq.gov/issue/measuring-harm-health-care-optimizing-adverse-event-review https://psnet.ahrq.gov

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44782/psn-pdf
     January 13, 2016 - The Swiss cheese model of adverse event occurrence—closing the holes. … The Swiss cheese model of adverse event occurrence--Closing the holes. … https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event-occurrence-closing-holes Shifting the … focus from individual failures to system problems has produced new ways to reduce adverse events. … https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event-occurrence-closing-holes https://psnet.ahrq.gov

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44772/psn-pdf
     January 13, 2016 - Post event debriefs: a commitment to learning how to better care for patients and staff. … Health care professionals who experience emotional consequences after adverse events are considered … event. … Further work should examine whether this approach ameliorates negative consequences of adverse events … https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events https

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47241/psn-pdf
     October 10, 2018 - Impact of high-reliability education on adverse event reporting by registered nurses. … Impact of High-Reliability Education on Adverse Event Reporting by Registered Nurses. … https://psnet.ahrq.gov/issue/impact-high-reliability-education-adverse-event-reporting-registered-nurses … training on high reliability and just culture for registered nurses did not lead them to report more adverse … https://psnet.ahrq.gov/issue/impact-high-reliability-education-adverse-event-reporting-registered-nurses

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867759/psn-pdf
     March 12, 2025 - Intrahospital patient transport: checklists, adverse events, and other considerations for the anesthesia … Intrahospital patient transport: checklists, adverse events, and other considerations for the anesthesia … https://psnet.ahrq.gov/issue/intrahospital-patient-transport-checklists-adverse-events-and-other- considerations-anesthesia … inter-hospital-transfer-independent-risk-factor-hospital-associated-infection https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport … https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport https://psnet.ahrq.gov/issue

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74172/psn-pdf
     December 08, 2021 - Differences in safety report event types submitted by graduate medical education trainees compared with … Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compared With … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education … - trainees-compared Adverse event reporting by health care providers, including medical trainees, is … //psnet.ahrq.gov/primer/reporting-patient-safety-events https://psnet.ahrq.gov/issue/does-error-and-adverse-event-reporting-physicians-and-nurses-differ

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38074/psn-pdf
     June 04, 2018 - Questions and Answers on FDA's Adverse Event Reporting System (FAERS). … https://psnet.ahrq.gov/issue/questions-and-answers-fdas-adverse-event-reporting-system-faers This FAQ … to quarterly reports and an interactive dashboard of medication-related incidents culled from FDA's Adverse … Event Reporting System (FAERS) database and identifies potential safety issues. … https://psnet.ahrq.gov/issue/questions-and-answers-fdas-adverse-event-reporting-system-faers

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37616/psn-pdf
     November 29, 2009 - 2007 Guide to State Adverse Event Reporting Systems. November 29, 2009 Rosenthal J, Takach M. … https://psnet.ahrq.gov/issue/2007-guide-state-adverse-event-reporting-systems Highlighting the large … increase in state adverse event reporting systems, this report finds that states are concentrating … https://psnet.ahrq.gov/issue/2007-guide-state-adverse-event-reporting-systems https://psnet.ahrq.gov/