-
psnet.ahrq.gov/node/47187/psn-pdf
September 05, 2018 - Supporting clinicians after adverse events: development
of a clinician peer support program. … Supporting Clinicians After Adverse Events: Development of a
Clinician Peer Support Program. … https://psnet.ahrq.gov/issue/supporting-clinicians-after-adverse-events-development-clinician-peer-support … event. … event.
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psnet.ahrq.gov/node/37181/psn-pdf
October 06, 2011 - Inter-rater reliability of a classification system for hospital
adverse drug event reports. … Inter-rater reliability of a classification system for hospital
adverse drug event reports. … https://psnet.ahrq.gov/issue/inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports … https://psnet.ahrq.gov/issue/inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports
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psnet.ahrq.gov/node/36490/psn-pdf
January 07, 2011 - randomised controlled trial of the effect of continuous
electronic physiological monitoring on the adverse … event
rate in high risk medical and surgical patients. … randomised controlled trial of the effect of continuous
electronic physiological monitoring on the adverse … event rate in high risk medical and surgical patients. … found that the higher intensity monitoring did not result in more treatment changes
or a reduction in adverse
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psnet.ahrq.gov/node/35553/psn-pdf
July 03, 2013 - Maximizing the Use of State Adverse Event Data to
Improve Patient Safety. … https://psnet.ahrq.gov/issue/maximizing-use-state-adverse-event-data-improve-patient-safety
This report … https://psnet.ahrq.gov/issue/maximizing-use-state-adverse-event-data-improve-patient-safety
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psnet.ahrq.gov/node/44217/psn-pdf
November 10, 2015 - Assessing the potential adoption and usefulness of
concurrent, action-oriented, electronic adverse drug … event triggers designed for the outpatient setting. … event triggers designed for the outpatient setting. … Trigger tools have been shown to be an efficient way to screen for adverse events. … This AHRQ-funded
study assessed the usefulness of different adverse drug event triggers in the outpatient
-
psnet.ahrq.gov/node/37550/psn-pdf
June 29, 2011 - Testing the technology acceptance model for evaluating
healthcare professionals' intention to use an adverse … event reporting system. … Testing the technology acceptance model for evaluating healthcare
professionals' intention to use an adverse … event reporting system. … psnet.ahrq.gov/issue/testing-technology-acceptance-model-evaluating-healthcare-professionals-
intention-use-adverse
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect … adverse drug
events in the hospital setting. … A systematic review of the performance characteristics of clinical
event monitor signals used to detect … adverse drug events in the hospital setting. … The authors analyzed the literature and identified laboratory and pharmacy triggers used to detect adverse
-
psnet.ahrq.gov/node/73473/psn-pdf
January 01, 2022 - Improving safety recommendations before
implementation: a simulation-based event analysis to
optimize … interventions designed to prevent recurrence of
adverse events. … Improving safety recommendations before implementation: a
simulation-based event analysis to optimize … interventions designed to prevent recurrence of adverse
events. … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event-
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psnet.ahrq.gov/node/44635/psn-pdf
June 21, 2016 - Evaluation of perioperative medication errors and adverse
drug events. … At least one medication error or adverse drug event
occurred in nearly half of the 277 operations observed … drug event; 80% of these errors were deemed
preventable. … There were no
differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists … ://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
https://psnet.ahrq.gov/issue/incidence-adverse-drug-events-and-potential-adverse-drug-events-implications-prevention
-
psnet.ahrq.gov/node/43567/psn-pdf
October 21, 2016 - National Action Plan for Adverse Drug Event Prevention. … https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
This national action … aims to align the efforts of multiple federal programs committed to reducing patient
harms related to adverse … common
usage and their very high potential to cause clinically significant, preventable, and measurable adverse … https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
https://psnet.ahrq.gov
-
psnet.ahrq.gov/node/45684/psn-pdf
January 01, 2020 - multilevel analysis of U.S. hospital patient safety
culture relationships with perceptions of voluntary event … Hospital Patient Safety Culture
Relationships With Perceptions of Voluntary Event Reporting. … However,
significant barriers to reporting exist and most systems capture only a fraction of adverse … Survey of Patient Safety Culture to better
understand what aspects of safety culture might affect event … https://psnet.ahrq.gov/issue/can-we-use-incident-reports-detect-hospital-adverse-events
https://psnet.ahrq.gov
-
psnet.ahrq.gov/node/35023/psn-pdf
March 04, 2011 - Building a framework for trust: critical event analysis of
deaths in surgical care. … Building a framework for trust: critical event analysis of deaths in surgical
care. … commentary discusses the role of the Scottish Audit of Surgical Mortality (SASM) on trends in adverse … Findings include a decrease over time in the percentage
of deaths for which adverse events in management … conclude that voluntary mortality audits may lead to important changes in practice and focusing on
adverse
-
psnet.ahrq.gov/node/45468/psn-pdf
October 11, 2017 - Identification and characterization of adverse drug events
in primary care. … Identification and Characterization of Adverse Drug Events in
Primary Care. … https://psnet.ahrq.gov/issue/identification-and-characterization-adverse-drug-events-primary-care
Adverse … drug event during a change in medications. … Less than 10% of patients
experienced an adverse drug event, which the authors conclude represents an
-
psnet.ahrq.gov/node/45871/psn-pdf
January 01, 2019 - The relationship between safety culture and voluntary
event reporting in a large regional ambulatory … The Relationship Between Safety Culture and Voluntary Event
Reporting in a Large Regional Ambulatory … https://psnet.ahrq.gov/issue/relationship-between-safety-culture-and-voluntary-event-reporting-large- … regional-ambulatory
Detection of adverse events is particularly challenging in ambulatory settings … These results suggest that safety culture promotes
reporting of adverse events.
-
psnet.ahrq.gov/issue/examining-validity-ahrqs-patient-safety-indicators-psis-variation-psi-composite-score-related
November 10, 2010 - drug event triggers designed for the outpatient setting. … September 25, 2019
Consensus building for development of outpatient adverse drug event … August 4, 2015
Using estimated true safety event rates versus flagged safety event rates … June 25, 2014
Using AHRQ Patient Safety Indicators to detect postdischarge adverse events … August 21, 2013
National trends in hospital-acquired preventable adverse events after
-
psnet.ahrq.gov/node/37701/psn-pdf
February 22, 2011 - Use of a handheld computer application for voluntary
medication event reporting by inpatient nurses … Use of a handheld computer application for voluntary
medication event reporting by inpatient nurses … https://psnet.ahrq.gov/issue/use-handheld-computer-application-voluntary-medication-event-reporting- … by low clinician reporting rates and the fact that
they identify a relatively small percentage of adverse … rates-and-types-events-reported-established-incident-reporting-systems-two-us-hospitals
https://psnet.ahrq.gov/issue/confidential-clinician-reported-surveillance-adverse-events-among-medical-inpatients
-
psnet.ahrq.gov/node/34845/psn-pdf
June 30, 2011 - The JCAHO patient safety event taxonomy: a
standardized terminology and classification schema for
near … misses and adverse events. … The JCAHO patient safety event taxonomy: a standardized
terminology and classification schema for near … misses and adverse events. … https://psnet.ahrq.gov/issue/jcaho-patient-safety-event-taxonomy-standardized-terminology-and-
classification-schema-near
-
psnet.ahrq.gov/node/45714/psn-pdf
December 20, 2017 - US emergency department visits for outpatient adverse
drug events, 2013–2014. … US Emergency Department Visits for Outpatient Adverse Drug
Events, 2013-2014. … Adverse drug events (ADEs) in outpatient settings can cause significant morbidity and mortality. … Drug Event Prevention. … https://psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
-
psnet.ahrq.gov/node/38935/psn-pdf
March 01, 2017 - December 23, 2016
Sentinel Event Alert. August 27, 2009;(43):1-3. … striving
to achieve high reliability status—consistently providing high quality care while minimizing adverse … In this sentinel event alert, the Joint Commission calls for senior health care leaders to establish … addressing errors at the sharp end, and maintain robust structures for analyzing and responding
to adverse … This Sentinel
Event Alert was retired in March 2017.
-
psnet.ahrq.gov/node/42882/psn-pdf
November 23, 2016 - Structuring patient and family involvement in medical
error event disclosure and analysis. … Structuring patient and family involvement in medical error event
disclosure and analysis. … https://psnet.ahrq.gov/issue/structuring-patient-and-family-involvement-medical-error-event-disclosure-and … Although patients and
family members may provide unique insights into adverse events, they are rarely … patient-engagement-and-safety
https://psnet.ahrq.gov/issue/what-can-hospitalized-patients-tell-us-about-adverse-events-learning-patient-reported