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8761. National Training Survey 2013: Concerns about Patient Safety. | PSNet
      psnet.ahrq.gov/issue/national-training-survey-2013-concerns-about-patient-safety
      July 15, 2015 - May 24, 2015 Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events … Physicians Quality and Safety Professionals Educators Medicine Epidemiology of Errors and Adverse

8762. Strategies for Creating, Sustaining, and Improving a Culture of Safety in Health Care, Second Edition. | PSNet
      psnet.ahrq.gov/issue/strategies-creating-sustaining-and-improving-culture-safety-health-care-second-edition
      May 20, 2015 - Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse … Topic Hospitals Facility and Group Administrators Medicine Epidemiology of Errors and Adverse

8763. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846148/psn-pdf
      March 15, 2023 - issue/near-miss-events-detected-using-emergency-department-trigger-tool https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors

8764. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74138/psn-pdf
      January 01, 2022 - combined-effect-psychological-and-social-capital-registered-nurses- experiencing-second Clinicians can experience adverse … alone and in combination with psychological capital) has a significant impact on the severity of these adverse … combined-effect-psychological-and-social-capital-registered-nurses-experiencing-second https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

8765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46402/psn-pdf
      March 20, 2018 - https://psnet.ahrq.gov/issue/safety-events-pediatric-out-hospital-cardiac-arrest Adverse events in prehospital

8766. Pharmacist's Role in Medication Safety | PSNet
      psnet.ahrq.gov/primer/pharmacists-role-medication-safety
      March 14, 2018 - Background As discussed in the related primer on medication error , adverse drug events occur when exposure … medication use Reviewing proper dosing with patients or providers can prevent medication errors and adverse … regimen; identify gaps in reaching treatment goals; or prevent prescription of medications that have adverse … Topic Pharmacists Hospital Pharmacy Community Pharmacy Medication Errors/Preventable Adverse … Drug Events Epidemiology of Errors and Adverse Events View More

8767. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43170/psn-pdf
      December 12, 2014 - effects-patient-environment-and-medication-related-factors-high-alert-medication-incidents https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events … ismps-list-high-alert-medications-acute-care-settings https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals https://psnet.ahrq.gov/issue/adverse-drug-events-among-hospitalized-medicare-patients-epidemiology-and-national-estimates

8768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46864/psn-pdf
      August 17, 2018 - intensive-care Clinical decision support systems in electronic health records (EHRs) aim to avert adverse … computerized-provider-order-entry-and-patient-safety https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

8769. 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

8770. 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

8771. 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

8772. 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

8773. 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.

8774. 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

8775. 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

8776. 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

8777. 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

8778. 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.

8779. 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.

8780. 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