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Showing results for "adverse event".
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9081. Medical Device Use Error: Root Cause Analysis. | PSNet
      psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
      January 10, 2018 - March 15, 2017 Prevention Is Better Than Cure: Learning From Adverse Events in Healthcare … May 3, 2023 Using the Generic Analysis Method to analyze sentinel event reports across

9082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36163/psn-pdf
      September 29, 2010 - The case study shares the experiences of the BTS, the positive impact they had on adverse events, and … improving-bar-coded-medication-administration-system-department-veterans-affairs https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-lessons-breakthrough-series-collaborative

9083. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35927/psn-pdf
      February 17, 2011 - conclusions are supported by a past effort at understanding the relationship between malpractice claims and adverse … https://psnet.ahrq.gov//#error https://psnet.ahrq.gov/issue/relation-between-malpractice-claims-and-adverse-events-due-negligence-results-harvard-medical

9084. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42229/psn-pdf
      July 03, 2014 - relationship-between-occurrence-surgical-complications-and-hospital-finances The business case for patient safety relies on the assumption that adverse … for the specific case of surgical complications—hospitals actually profit when patients experience adverse

9085. Association of cataract surgical outcomes with late surgeon career stages: a population-based cohort study. | PSNet
      psnet.ahrq.gov/issue/association-cataract-surgical-outcomes-late-surgeon-career-stages-population-based-cohort
      September 23, 2020 - Overall, adverse surgical events did not differ by career stage, although very small increases in risk … 2020 Effect of computerized provider order entry with clinical decision support on adverse … March 5, 2025 Factors influencing the reporting of adverse medical device events: qualitative

9086. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39394/psn-pdf
      May 25, 2010 - ://psnet.ahrq.gov/issue/iatrogenic-events-contributing-icu-admission-prospective-study Preventable adverse

9087. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42160/psn-pdf
      April 03, 2013 - perianesthesia-nurses-role-prevention-opioid-related-sentinel-events This commentary reviews strategies to prevent adverse

9088. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49654/psn-pdf
      June 01, 2012 - 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 … 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.

9089. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
      April 01, 2025 - /sentinel-event-alert- newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls … /sentinel-event-alert-newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls-and-hazardous-condi … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … identify how human factors and systems issues contributed to the event. … Patient Safety Primer: Medication Errors and Adverse Drug Events 18. Person-Centered Care 19.

9090. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47959/psn-pdf
      May 15, 2019 - psnet.ahrq.gov/issue/detecting-and-treating-suicide-ideation-all-settings https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors

9091. Perceptions of pediatric hospital safety culture in the United States: an analysis of the 2016 Hospital Survey on Patient Safety Culture. | PSNet
      psnet.ahrq.gov/issue/perceptions-pediatric-hospital-safety-culture-united-states-analysis-2016-hospital-survey
      January 19, 2022 - June 3, 2013 Prospective validation of classification of intraoperative adverse events … Research and Quality pediatric indicators as a quality metric for surgery in children: do they predict adverse … February 1, 2012 An intervention to decrease narcotic-related adverse drug events in

9092. We want to know: eliciting hospitalized patients' perspectives on breakdowns in care. | PSNet
      psnet.ahrq.gov/issue/we-want-know-eliciting-hospitalized-patients-perspectives-breakdowns-care
      January 12, 2022 - Prior studies have shown that patient surveys can identify errors and adverse events that were not detected … October 17, 2017 Patients' reports of adverse events: a data linkage study of Australian … Hospitals Physicians Facility and Group Administrators Medicine Epidemiology of Errors and Adverse

9093. 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

9094. 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

9095. 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

9096. 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-

9097. 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.

9098. 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

9099. 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

9100. 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