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Showing results for "adverse event".
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8761. Laparoscopic bile duct injury: understanding the psychology and heuristics of the error. | PSNet
      psnet.ahrq.gov/issue/laparoscopic-bile-duct-injury-understanding-psychology-and-heuristics-error
      May 29, 2014 - May 25, 2016 A systems approach to analyzing and preventing hospital adverse events. … November 6, 2019 Impact of critical event checklists on anaesthetist performance in simulated

8762. Preventing retained surgical items. | PSNet
      psnet.ahrq.gov/issue/preventing-retained-surgical-items
      December 07, 2022 - February 24, 2021 The impact of drug error reduction software on preventing harmful adverse … Related Resources Grading recommendations for enhanced patient safety in sentinel event

8763. Dangerous wrong-route errors with tranexamic acid. | PSNet
      psnet.ahrq.gov/issue/dangerous-wrong-route-errors-tranexamic-acid
      February 18, 2014 - August 23, 2023 Latent and active failures perfectly align to allow a preventable adverse … event to reach a patient.

8764. A just culture after Mid Staffordshire. | PSNet
      psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire
      February 11, 2009 - May 25, 2016 A systems approach to analyzing and preventing hospital adverse events. … July 17, 2019 Leading a highly visible hospital through a serious reportable event.

8765. Design for reliability: barcoded medication administration. | PSNet
      psnet.ahrq.gov/issue/design-reliability-barcoded-medication-administration
      July 21, 2021 - November 18, 2020 Nursing implications of an early warning system implemented to reduce adverse … I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event

8766. Patient handoffs. | PSNet
      psnet.ahrq.gov/issue/patient-handoffs
      June 17, 2014 - July 19, 2023 Families as partners in hospital error and adverse event surveillance.

8767. Improving care transitions: optimizing medication reconciliation. | PSNet
      psnet.ahrq.gov/issue/improving-care-transitions-optimizing-medication-reconciliation
      June 17, 2014 - April 10, 2024 Using event reports in real-time to identify and mitigate patient safety … Topic Hospitals Pharmacists Pharmacy Medication Safety Medication Errors/Preventable Adverse

8768. A practical tool to learn from defects in patient care. | PSNet
      psnet.ahrq.gov/issue/practical-tool-learn-defects-patient-care
      September 28, 2010 - May 20, 2015 Medication event huddles: a tool for reducing adverse drug events.

8769. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
      January 01, 2019 - OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect … OF UNSAFE CONDITION (EVENT TYPE) excluded the following: adverse drug events with no apparent incorrect

8770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41193/psn-pdf
      August 02, 2012 - Medicaid, hospital financial stress, and the incidence of adverse medical events for children. … Medicaid, hospital financial stress, and the incidence of adverse medical events for children. … https://psnet.ahrq.gov/issue/medicaid-hospital-financial-stress-and-incidence-adverse-medical-events- … event. … event.

8771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37642/psn-pdf
      March 26, 2008 - Medication, allergy, and adverse drug event discrepancies in ambulatory care. … Medication, allergy, and adverse drug event discrepancies in ambulatory care. … https://psnet.ahrq.gov/issue/medication-allergy-and-adverse-drug-event-discrepancies-ambulatory-care … https://psnet.ahrq.gov/issue/medication-allergy-and-adverse-drug-event-discrepancies-ambulatory-care

8772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37181/psn-pdf
      October 06, 2011 - Inter-rater reliability of a classification system for hospital adverse drug event reports. … Inter-rater reliability of a classification system for hospital adverse drug event reports. … https://psnet.ahrq.gov/issue/inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports … https://psnet.ahrq.gov/issue/inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports

8773. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44217/psn-pdf
      November 10, 2015 - Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug … event triggers designed for the outpatient setting. … event triggers designed for the outpatient setting. … Trigger tools have been shown to be an efficient way to screen for adverse events. … This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient

8774. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36895/psn-pdf
      March 10, 2011 - A systematic review of the performance characteristics of clinical event monitor signals used to detect … adverse drug events in the hospital setting. … A systematic review of the performance characteristics of clinical event monitor signals used to detect … adverse drug events in the hospital setting. … The authors analyzed the literature and identified laboratory and pharmacy triggers used to detect adverse

8775. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44635/psn-pdf
      June 21, 2016 - Evaluation of perioperative medication errors and adverse drug events. … At least one medication error or adverse drug event occurred in nearly half of the 277 operations observed … drug event; 80% of these errors were deemed preventable. … There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists … ://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events https://psnet.ahrq.gov/issue/incidence-adverse-drug-events-and-potential-adverse-drug-events-implications-prevention

8776. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73473/psn-pdf
      January 01, 2022 - Improving safety recommendations before implementation: a simulation-based event analysis to optimize … interventions designed to prevent recurrence of adverse events. … Improving safety recommendations before implementation: a simulation-based event analysis to optimize … interventions designed to prevent recurrence of adverse events. … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event-

8777. Data Collection Form | Digital Healthcare Research
      digital.ahrq.gov/document-type/data-collection-form
      January 01, 2023 - ADE Incident Identification Form Description This form identifies an adverse … drug event using data reported by a clinician. … Chart Review Form Description This is a chart review form for an adverse … drug event (ADE) study. … drug event study.

8778. 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

8779. 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

8780. 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