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Showing results for "adverse event".
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8581. The evolution of error: error management, cognitive constraints, and adaptive decision-making biases. | PSNet
      psnet.ahrq.gov/issue/evolution-error-error-management-cognitive-constraints-and-adaptive-decision-making-biases
      June 03, 2020 - October 19, 2022 Families as partners in hospital error and adverse event surveillance

8582. Improving medication administration safety in a community hospital setting using Lean methodology. | PSNet
      psnet.ahrq.gov/issue/improving-medication-administration-safety-community-hospital-setting-using-lean-methodology
      September 23, 2020 - January 23, 2017 Elucidating reasons for resident underutilization of electronic adverse … event reporting.

8583. Cognitive bias in clinical medicine. | PSNet
      psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
      February 20, 2019 - August 4, 2021 Families as partners in hospital error and adverse event surveillance.

8584. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40904/psn-pdf
      January 04, 2012 - Effect of illness severity and comorbidity on patient safety and adverse events. … Effect of illness severity and comorbidity on patient safety and adverse events. … https://psnet.ahrq.gov/issue/effect-illness-severity-and-comorbidity-patient-safety-and-adverse-events … The likelihood of suffering an adverse event is directly tied to length of hospitalization, and this … By linking adverse event data from various sources—including Patient Safety Indicators, voluntary error

8585. Environmental Safety in the OR | PSNet
      psnet.ahrq.gov/web-mm/environmental-safety-or
      May 19, 2015 - Root cause analysis, on the other hand, investigates sentinel events—serious adverse events that may … March 26, 2008 Inter-rater reliability of a classification system for hospital adverse … drug event reports. … March 2, 2022 Risk factors for hospital admissions associated with adverse drug events … July 19, 2023 Understanding the root cause analysis process to increase safety event

8586. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37135/psn-pdf
      October 04, 2011 - Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse … event classification. … Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse … event classification. … psnet.ahrq.gov/issue/combining-ratings-multiple-physician-reviewers-helped-overcome-uncertainty- associated-adverse

8587. In Conversation With…Kaveh G. Shojania, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
      September 01, 2011 - it was painless and costless—you wouldn't want detailed and nuanced individual information about the event … It's ironic that the single most commonly reported incident at most hospitals is not the type of event … relatively frequent problem, and there's already a fair amount known about the risk factors for the event … Adverse-event-reporting practices by US hospitals: results of a national survey. … Developing an adverse event reporting system using administrative data.

8588. Psn-Pdf (pdf file)
      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-

8589. Psn-Pdf (pdf file)
      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

8590. Psn-Pdf (pdf file)
      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

8591. Psn-Pdf (pdf file)
      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

8592. Psn-Pdf (pdf file)
      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

8593. Psn-Pdf (pdf file)
      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.

8594. Psn-Pdf (pdf file)
      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

8595. Psn-Pdf (pdf file)
      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

8596. Psn-Pdf (pdf file)
      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

8597. Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors? | PSNet
      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

8598. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35889/psn-pdf
      March 10, 2011 - Automated surveillance for adverse drug events at a community hospital and an academic medical center … Automated surveillance for adverse drug events at a community hospital and an academic medical center … https://psnet.ahrq.gov/issue/automated-surveillance-adverse-drug-events-community-hospital-and- academic-medical-center … This study determined that an automated adverse drug event (ADE) surveillance system captured higher … event rates than did existing voluntary systems, particularly in a community setting.

8599. Psn-Pdf (pdf file)
      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.

8600. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47189/psn-pdf
      August 17, 2018 - Association of opioid-related adverse drug events with clinical and cost outcomes among surgical patients … Association of Opioid-Related Adverse Drug Events With Clinical and Cost Outcomes Among Surgical Patients … https://psnet.ahrq.gov/issue/association-opioid-related-adverse-drug-events-clinical-and-cost-outcomes … drug event during their admission. … Patients who experienced an opioid-related adverse drug event had longer hospital stays, greater inpatient