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Showing results for "adverse event".
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8941. The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study. | PSNet
      psnet.ahrq.gov/issue/impact-type-manual-medication-cart-filling-method-frequency-medication-administration-errors
      January 23, 2019 - The influence that electronic prescribing has on medication errors and preventable adverse … March 4, 2011 Reliability of the assessment of preventable adverse drug events in daily … December 10, 2014 Adverse drug events in hospitalized cardiac patients.

8942. The lingering safety menace: a 10-year review of enteral misconnection adverse events and narrative review. | PSNet
      psnet.ahrq.gov/issue/lingering-safety-menace-10-year-review-enteral-misconnection-adverse-events-and-narrative
      January 06, 2017 - Review The lingering safety menace: a 10-year review of enteral misconnection adverse … The lingering safety menace: A 10‐year review of enteral misconnection adverse events and narrative review … The lingering safety menace: A 10‐year review of enteral misconnection adverse events and narrative review

8943. Risk management, or just a different risk: a national survey of newborn units following a patient safety alert. | PSNet
      psnet.ahrq.gov/issue/risk-management-or-just-different-risk-national-survey-newborn-units-following-patient-safety
      April 12, 2011 - February 14, 2017 Reducing drug prescription errors and adverse drug events by application … September 6, 2016 Adverse drug events in a paediatric intensive care unit: a prospective … June 9, 2011 Adverse events in the neonatal intensive care unit: development, testing

8944. Culture, language, and patient safety: making the link. | PSNet
      psnet.ahrq.gov/issue/culture-language-and-patient-safety-making-link
      June 22, 2009 - and stress that not sufficiently addressing this relationship may put minority patients at risk for adverse … Related Resources Humanizing harm: using a restorative approach to heal and learn from adverse … November 24, 2010 Introduction of discharge plan to reduce adverse events within 72 hours

8945. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). | PSNet
      psnet.ahrq.gov/issue/impact-pharmacist-involvement-transitional-care-high-risk-patients-through-medication
      August 25, 2011 - Medication errors are a common cause of adverse events after hospital discharge . … found that integrating pharmacists into the discharge process improved patient satisfaction and reduced adverse … August 25, 2011 The effect of hospitalist discontinuity on adverse events.

8946. Opioids and Dentistry. | PSNet
      psnet.ahrq.gov/issue/opioids-and-dentistry
      November 12, 2014 - July 29, 2020 Medication safety: reducing anesthesia medication errors and adverse drug … April 11, 2018 Classifying adverse events in the dental office. … September 6, 2017 Patient safety incidents and adverse events in ambulatory dental care

8947. The Science of Improving Patient Safety and Identifying Defects: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
      December 01, 2017 - Surgery is linked to 50% of all hospital adverse events. … Most hospital adverse events are AVOIDABLE. Slide 6: How Do These Errors Happen? … Slide 16: Communication Breakdowns 6 Images: Four bar graphs showing root causes of adverse events … In each graph, communication is the most common root cause of each event.  … Event reporting systems, liability claims, sentinel events, morbidity and mortality conferences.

8948. PSO Quiz--Question Sheet (pdf file)
      pso.ahrq.gov/sites/default/files/quiz/pso-quiz-questions.pdf
      January 01, 2020 - risk management department, the nurse prepares a written statement documenting her observations of an adverse … event to put the hospital’s professional liability insurer on notice of a potential claim.

8949. Title Page (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015270-hayden-final-report-2008.pdf
      January 01, 2008 - www.ahrq.gov 2 Abstract Purpose: The purpose of this project was to reduce medical errors and adverse … 3 Final Report Purpose The purpose of this project was to reduce medical errors and adverse … The Quality Management module has replaced SVMC’s old home-grown event reporting system. … This may be because of the relative attention the SNAP and the “Swiss cheese model” of adverse events … The disparity between the lack of change in beliefs that surround reporting of adverse events and near

8950. Perceptions of radiation safety culture in medical imaging by role. | PSNet
      psnet.ahrq.gov/issue/perceptions-radiation-safety-culture-medical-imaging-role
      September 27, 2023 - September 1, 2012 IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events … March 30, 2022 Collaborative case review: a systems-based approach to patient safety event

8951. The effects of harm events on 30-day readmission in surgical patients. | PSNet
      psnet.ahrq.gov/issue/effects-harm-events-30-day-readmission-surgical-patients
      July 31, 2019 - February 15, 2017 Association of opioid-related adverse drug events with clinical and … Improving Diagnostic Safety and Quality April 26, 2023 Adverse

8952. Disclosure coaching: an ask-tell-ask model to support clinicians in disclosure conversations. | PSNet
      psnet.ahrq.gov/issue/disclosure-coaching-ask-tell-ask-model-support-clinicians-disclosure-conversations
      December 18, 2014 - December 15, 2021 Structuring patient and family involvement in medical error event disclosure … See More About The Topic Hospitals Physicians Medicine Epidemiology of Errors and Adverse

8953. 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

8954. 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

8955. 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

8956. 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-

8957. 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.

8958. 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

8959. 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

8960. 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