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Showing results for "adverse event".
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9521. Survey of nurses' experiences applying The Joint Commission's medication management titration standards. | PSNet
      psnet.ahrq.gov/issue/survey-nurses-experiences-applying-joint-commissions-medication-management-titration
      September 15, 2021 - November 4, 2015 Using a patient internet portal to prevent adverse drug events: a randomized … The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event

9522. Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement. | PSNet
      psnet.ahrq.gov/issue/investigating-impact-cognitive-bias-nursing-documentation-decision-making-and-judgement
      July 13, 2022 - Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse … November 9, 2022 Developing and aligning a safety event taxonomy for inpatient psychiatry

9523. Approaches to improving patient safety in integrated care: a scoping review. | PSNet
      psnet.ahrq.gov/issue/approaches-improving-patient-safety-integrated-care-scoping-review
      May 18, 2022 - Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse … November 30, 2021 Organizational characteristics and perceptions of clinical event

9524. Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness. | PSNet
      psnet.ahrq.gov/issue/analysis-academic-medical-centers-corrective-action-plan-response-fatal-medication-error
      February 21, 2018 - System-based strategies are considered the most effective in reducing adverse events. … the proposed action plan of an academic medical center following a fatal medication administration event

9525. Medication errors in community pharmacies: evaluation of a standardized safety program. | PSNet
      psnet.ahrq.gov/issue/medication-errors-community-pharmacies-evaluation-standardized-safety-program
      June 29, 2022 - Event type, severity, medication class, and method of detection are described. … Outpatient Pharmacy Policy Makers Community Pharmacy Medication Errors/Preventable Adverse

9526. Development and evaluation of a checklist to support decision making in cancer multidisciplinary team meetings: MDT-QuIC. | PSNet
      psnet.ahrq.gov/issue/development-and-evaluation-checklist-support-decision-making-cancer-multidisciplinary-team
      September 25, 2011 - Delayed Diagnoses of Cancer July 31, 2023 Association between cancer-specific adverse … event triggers and mortality: a validation study.

9527. The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics. | PSNet
      psnet.ahrq.gov/issue/use-medical-emergency-teams-medical-and-surgical-patients-impact-patient-nurse-and
      November 09, 2011 - December 12, 2012 Families as partners in hospital error and adverse event surveillance

9528. Reducing falls in hospitalized children and adolescents with cancer and blood disorders: a quality improvement journey. | PSNet
      psnet.ahrq.gov/issue/reducing-falls-hospitalized-children-and-adolescents-cancer-and-blood-disorders-quality
      November 16, 2022 - Falls with injury are a never event. … August 5, 2015 Incidence and nature of adverse events during pediatric sedation/anesthesia

9529. Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital. | PSNet
      psnet.ahrq.gov/issue/retrospective-review-emergency-response-activations-during-13-year-period-tertiary-care
      August 26, 2020 - RIS Download Citation Related Resources From the Same Author(s) Adverse … Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event

9530. Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors. | PSNet
      psnet.ahrq.gov/issue/development-and-implementation-subcutaneous-insulin-pen-label-bar-code-scanning-protocol
      October 19, 2022 - October 19, 2022 Uptake of quality-related event standards of practice by community pharmacies … Inappropriate hospital admission as a risk factor for the subsequent development of adverse

9531. Diagnostic errors in primary care pediatrics: Project RedDE. | PSNet
      psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-redde
      April 08, 2018 - November 16, 2022 Families as partners in hospital error and adverse event surveillance

9532. Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research. | PSNet
      psnet.ahrq.gov/issue/hospital-board-oversight-quality-and-patient-safety-narrative-review-and-synthesis-recent
      November 13, 2019 - January 23, 2019 Inpatient suicide: preventing a common sentinel event. … October 19, 2012 Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries

9533. 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.

9534. 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

9535. 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

9536. 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

9537. 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

9538. 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.

9539. 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.

9540. 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