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Showing results for "adverse event".
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9161. Finding and fixing diagnosis errors: can triggers help? | PSNet
      psnet.ahrq.gov/issue/finding-and-fixing-diagnosis-errors-can-triggers-help
      January 31, 2024 - Physicians Health Care Executives and Administrators Medicine Diagnostic Errors Computerized Adverse … Event Detection View More

9162. Medical malpractice liability in the age of electronic health records. | PSNet
      psnet.ahrq.gov/issue/medical-malpractice-liability-age-electronic-health-records
      April 05, 2013 - An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement

9163. An objective study of the impact of the electronic medical record on outcomes in trauma patients. | PSNet
      psnet.ahrq.gov/issue/objective-study-impact-electronic-medical-record-outcomes-trauma-patients
      October 13, 2018 - November 1, 2012 Families as partners in hospital error and adverse event surveillance

9164. A resident-led institutional patient safety and quality improvement process. | PSNet
      psnet.ahrq.gov/issue/resident-led-institutional-patient-safety-and-quality-improvement-process
      November 16, 2022 - September 15, 2011 Performance characteristics of a methodology to quantify adverse events … June 17, 2014 Patient safety event reporting expectation: does it influence residents

9165. Medical trainees' formal and informal incident reporting across a five-hospital academic medical center. | PSNet
      psnet.ahrq.gov/issue/medical-trainees-formal-and-informal-incident-reporting-across-five-hospital-academic-medical
      May 10, 2016 - July 2, 2014 Adverse events and burnout: the moderating effects of workgroup identification … May 21, 2019 The effects of power, leadership and psychological safety on resident event

9166. What did the doctor say? Health literacy and recall of medical instructions. | PSNet
      psnet.ahrq.gov/issue/what-did-doctor-say-health-literacy-and-recall-medical-instructions
      December 21, 2014 - September 23, 2020 Families as partners in hospital error and adverse event surveillance

9167. Bar code technology and medication administration error. | PSNet
      psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error
      June 07, 2023 - February 24, 2011 A multi-site assessment of inpatient safety event rates during the … October 1, 2013 US emergency department visits for outpatient adverse drug events, 2013

9168. Nursing mortality and morbidity and journal club cycles: paving the way for nursing autonomy, patient safety, and evidence-based practice. | PSNet
      psnet.ahrq.gov/issue/nursing-mortality-and-morbidity-and-journal-club-cycles-paving-way-nursing-autonomy-patient
      February 03, 2011 - June 3, 2020 Reporting of perioperative adverse events by pediatric anesthesiologists … July 2, 2014 Sepsis: recognizing the next event.

9169. Application of human error theory in case analysis of wrong procedures. | PSNet
      psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures
      November 14, 2018 - October 19, 2022 Families as partners in hospital error and adverse event surveillance

9170. Patient Mix-Up | PSNet
      psnet.ahrq.gov/web-mm/patient-mix
      December 01, 2007 - any medication, and thus might receive one to which they are either allergic or likely to develop an adverse … In one large study of medication errors and adverse drug events, the stages of serious medication errors … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Relationship between medication errors and adverse drug events. … Figure Distribution of Adverse Drug Events According to the Stage of the Error in the Medication Process

9171. Disclosure of Errors | PSNet
      psnet.ahrq.gov/primer/disclosure-errors
      September 15, 2024 - institutions have implemented " communication-and-response " strategies that emphasize early disclosure of adverse … This model includes full disclosure of adverse events, appropriate investigations, implementation of … Current Context Disclosure of errors and adverse events is now endorsed by a broad array of organizations … August 10, 2022 Disclosing adverse events in clinical practice: the delicate act of being open.

9172. Disruptive and Unprofessional Behavior | PSNet
      psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
      September 15, 2024 - nursing dissatisfaction and likelihood of leaving the nursing profession , and has been linked to adverse … The seriousness of this issue was underscored by a 2008 Joint Commission sentinel event alert , which … Preventing and Addressing Disruptive Behavior As the sentinel event alert noted, "There is a history … A subsequent sentinel event alert issued in March 2017, and updated in 2021,  reinforced the importance

9173. Getting to the Root of the Matter | PSNet
      psnet.ahrq.gov/web-mm/getting-root-matter
      September 01, 2005 - The magnitude of medical error, the relative contribution of errors to adverse patient outcomes, and … The theory underlying an RCA is to move the understanding of adverse event analysis away from individual … We do have a small amount of additional information from this event available to us to review. … Incidence of adverse drug events and potential adverse drug events. Implications for prevention. … Systems analysis of adverse drug events. ADE Prevention Study Group.

9174. 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

9175. 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

9176. 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-

9177. 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.

9178. 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

9179. 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

9180. 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