Results

Total Results: over 10,000 records

Showing results for "adverse event".
Users also searched for: patient safety indicators

8941. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
      June 01, 2015 - encounters, this patient's severe peripheral arterial disease was misdiagnosed This error led to a serious adverse … event The case provides an opportunity to discuss diagnostic reasoning and heuristics This piece will … Ambulatory care adverse events and preventable adverse events leading to a hospital admission. … or application of a computerized diagnostic aid might have prevented this error and the subsequent adverse … event 25 25 Take-Home Points Anchoring is the tendency to stick with initial impressions even as

8942. Predicting and preventing adverse drug reactions in the very old. | PSNet
      psnet.ahrq.gov/issue/predicting-and-preventing-adverse-drug-reactions-very-old
      April 16, 2018 - Study Predicting and preventing adverse drug reactions in the very old. … Predicting and preventing adverse drug reactions in the very old. Drugs Aging. 2005;22(5):375-92. … The authors evaluate pathophysiological factors associated with adverse drug reactions (ADRs) in elderly … Predicting and preventing adverse drug reactions in the very old. … Part I: Sensitivity of the elderly to adverse drug reactions.

8943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49427/psn-pdf
      January 01, 2004 - The Commentary Adverse events occur during 3%-39% of all surgical admissions, with the operating room … if ever, used to investigate intra-operative occurrences that don't rise to the level of "sentinel event … The incidence and nature of surgical adverse events in Colorado and Utah in 1992. … Incidence of adverse events and negligence in hospitalized patients. … An alternative strategy for studying adverse events in medical care.

8944. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet
      psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
      October 27, 2021 - Following treatment of LAST, the patient should be observed for at least 2 hours after a CNS event and … for 4-6 hours after a cardiovascular event, but clinical decision making should depend on the severity … Sentinel Event Data – Root Causes by Event Type, 2004 – 2014. … May 8, 2024 Prescription opioid dose reductions and potential adverse events: a multi-site … November 4, 2020 When safety event reporting is seen as punitive: "I've been PSN-ed!"

8945. Transfer Troubles | PSNet
      psnet.ahrq.gov/web-mm/transfer-troubles
      December 29, 2014 - Understand the frequency of errors and adverse events in the transfer of patients between hospitals. … Describe how communication lapses can lead to errors and adverse events in the transfer of patients between … transfers, it has been shown that adverse events can occur in 1% to 34% of critical care transfers.( … 4,7,8 ) In one study, approximately 17% of the adverse events resulted in potential harm to patients … Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15:923-931.

8946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47674/psn-pdf
      December 19, 2018 - Family-centered rounds reduced both preventable and nonpreventable adverse events. … psnet.ahrq.gov/primer/patient-engagement-and-safety https://psnet.ahrq.gov/issue/can-we-rely-patients-reports-adverse-events

8947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38612/psn-pdf
      May 06, 2009 - assessing-controlled-substance-prescribing-errors-pediatric-teaching-hospital-analysis-safety https://psnet.ahrq.gov/issue/adverse-drug-events-pediatric-outpatients … ismps-list-high-alert-medications-acute-care-settings https://psnet.ahrq.gov/issue/national-surveillance-emergency-department-visits-outpatient-adverse-drug-events-children-and

8948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46424/psn-pdf
      March 20, 2018 - electronic-triggers-identify-delays-follow-mammography-harnessing-power-big- data-health-care Electronic triggers are critical tools for detecting adverse … primer/triggers-and-trigger-tools https://psnet.ahrq.gov/issue/introduction-trigger-tools-identifying-adverse-events

8949. 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

8950. 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

8951. 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

8952. 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

8953. 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.

8954. 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

8955. 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

8956. 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

8957. 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

8958. 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.

8959. 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.

8960. 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