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Showing results for "adverse event".
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8801. Cleaning up the discharge process: a number of components—and personnel—are crucial to success. | PSNet
      psnet.ahrq.gov/issue/cleaning-discharge-process-number-components-and-personnel-are-crucial-success
      October 20, 2021 - I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event … March 30, 2011 Cascade iatrogenesis: factors leading to the development of adverse events

8802. Pharmacists' medication reconciliation-related clinical interventions in a children's hospital. | PSNet
      psnet.ahrq.gov/issue/pharmacists-medication-reconciliation-related-clinical-interventions-childrens-hospital
      February 27, 2009 - June 21, 2017 Families as partners in hospital error and adverse event surveillance.

8803. Diagnostic decision-making in the emergency department. | PSNet
      psnet.ahrq.gov/issue/diagnostic-decision-making-emergency-department
      December 16, 2020 - December 5, 2018 Adverse drug event–related emergency department visits associated with

8804. Practice Advisory on Intraoperative Awareness and Brain Function Monitoring. | PSNet
      psnet.ahrq.gov/issue/practice-advisory-intraoperative-awareness-and-brain-function-monitoring
      July 16, 2018 - July 16, 2018 Using event reports in real-time to identify and mitigate patient safety … Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression May 27, 2020 Adverse

8805. Using a quantitative risk register to promote learning from a patient safety reporting system. | PSNet
      psnet.ahrq.gov/issue/using-quantitative-risk-register-promote-learning-patient-safety-reporting-system
      September 24, 2010 - July 29, 2020 Effect of hospital follow-up appointment on clinical event outcomes and … Hospitals Health Care Providers Risk Managers Medicine Epidemiology of Errors and Adverse

8806. Patient safety knowledge and its determinants in medical trainees. | PSNet
      psnet.ahrq.gov/issue/patient-safety-knowledge-and-its-determinants-medical-trainees
      July 29, 2020 - May 2, 2018 Housestaff and medical student attitudes toward medical errors and adverse … 13, 2011 Effectiveness of a graduate medical education program for improving medical event

8807. The lost art of doctoring: reflections of a pediatric resident. | PSNet
      psnet.ahrq.gov/issue/lost-art-doctoring-reflections-pediatric-resident
      November 21, 2021 - Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse … October 29, 2017 Increasing patient safety event reporting in an emergency medicine residency

8808. Disclosure programmes in the US--an inadequate response to medical error. | PSNet
      psnet.ahrq.gov/issue/disclosure-programmes-us-inadequate-response-medical-error
      October 25, 2023 - CRPs) are an important strategy supporting full disclosure and psychological healing after a medical adverse … Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event

8809. 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

8810. 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

8811. 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

8812. 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

8813. 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.

8814. 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

8815. 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

8816. 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

8817. 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

8818. 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.

8819. 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.

8820. 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