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8841. The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety. | PSNet
      psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient-safety
      November 18, 2020 - solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event … The Topic Ambulatory Care Health Care Providers Medicine Epidemiology of Errors and Adverse

8842. Impact of hospital accreditation on quality improvement in healthcare: a systematic review. | PSNet
      psnet.ahrq.gov/issue/impact-hospital-accreditation-quality-improvement-healthcare-systematic-review
      September 23, 2020 - May 11, 2014 View More Related Resources Lessons from Event Reports … September 20, 2023 Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are

8843. Written Signout: It Only Works If You Use The Right One | PSNet
      psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
      April 24, 2018 - Fortunately, the patient did not experience any adverse consequences as a result of the error. … Sentinel Event Alert. Inadequate hand-off communication. September 11, 2017;(58):1-6. … Rates of medical errors and preventable adverse events among hospitalized children following implementation … Related Resources From the Same Author(s) Families as partners in hospital error and adverse … event surveillance.

8844. Dangerous Dapsone | PSNet
      psnet.ahrq.gov/web-mm/dangerous-dapsone
      January 10, 2011 - Fortunately for this patient, this mistake did not cause her adverse long-term clinical consequences. … Clinical pharmacists have a positive impact on adverse drug events ( 13,14 ), yet in this case a phone … Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. … Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units … February 14, 2024 Adverse safety events in emergency medical services care of children

8845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42454/psn-pdf
      September 09, 2013 - The project led to an 11% reduction in preventable adverse events, but hospital reimbursements decreased … relationship-between-occurrence-surgical-complications-and-hospital-finances https://psnet.ahrq.gov/issue/how-guide-prevent-obstetrical-adverse-events

8846. Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. | PSNet
      psnet.ahrq.gov/issue/overcoming-barriers-adopting-and-implementing-computerized-physician-order-entry-systems-us
      July 10, 2008 - June 28, 2010 Medication dispensing errors and potential adverse drug events before and … January 7, 2015 Relationship between medication event rates and the Leapfrog computerized

8847. Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis. | PSNet
      psnet.ahrq.gov/issue/think-twice-effects-diagnostic-accuracy-returning-case-reflect-upon-initial-diagnosis
      June 08, 2022 - September 23, 2020 Collaborative case review: a systems-based approach to patient safety event … February 22, 2023 Structural racism and adverse maternal health outcomes: a systematic

8848. Pediatric faculty knowledge and comfort discussing diagnostic errors: a pilot survey to understand barriers to an educational program. | PSNet
      psnet.ahrq.gov/issue/pediatric-faculty-knowledge-and-comfort-discussing-diagnostic-errors-pilot-survey-understand
      April 22, 2020 - April 22, 2020 Adverse events associated with procedural sedation and analgesia in a … October 16, 2024 A systemwide strategy to embed equity into patient safety event analysis

8849. 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

8850. 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

8851. 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

8852. 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

8853. 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.

8854. 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

8855. 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

8856. 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

8857. 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

8858. 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.

8859. 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.

8860. 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