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Showing results for "adverse event".
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9181. Update on Safety Culture | PSNet
      psnet.ahrq.gov/perspective/update-safety-culture
      January 22, 2020 - Recent evidence shows that roughly one in three hospitalized patients experiences an adverse event, and … in 6% of cases the adverse event is severe enough to prolong the patient's hospitalization and send … 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously

9182. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/juvenile-arthritis-dmards_disposition-comments.pdf
      September 01, 2011 - We have added the following sentence as a Key Point: “Adverse event rates may be underestimated by … In adverse event analysis, page 45, why weren't open label run-in phase data in the withdrawal studies … In the adverse event analysis, we only included data from the RCT phases of multiphase studies in order … Some examples of imbalances in adverse event rates that favor the safety of placebo over adalimumab … We have added the following sentence as a Key Point for KQ3: “Adverse event rates may be underestimated

9183. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - A formal root cause analysis of the case found many errors that led to the adverse events. … At the same time, there are event types particular to inpatient psychiatry, often linked to the abnormal … Affairs (VA) hospitals.( 2 ) From this analysis of electronic health records, the rate of any safety event … For some potential medical etiologies (e.g., delirium, seizure, cerebral vascular event, severe infection … event reporting mechanism.

9184. Evaluation of drug utilization and prescribing errors in infants: a primary care prescription-based study. | PSNet
      psnet.ahrq.gov/issue/evaluation-drug-utilization-and-prescribing-errors-infants-primary-care-prescription-based
      March 16, 2022 - September 13, 2011 Adverse drug events resulting from patient errors in older adults. … 20, 2011 High risk prescribing in primary care patients particularly vulnerable to adverse … July 6, 2011 Diagramming patients' views of root causes of adverse drug events in ambulatory

9185. Transitions from one electronic health record to another: challenges, pitfalls, and recommendations. | PSNet
      psnet.ahrq.gov/issue/transitions-one-electronic-health-record-another-challenges-pitfalls-and-recommendations
      March 17, 2021 - Prior studies have shown that adverse events can increase during the implementation of a new electronic … December 7, 2022 Inaccurate penicillin allergy labeling, the electronic health record, and adverse … 2021 Transforming the medication regimen review process using telemedicine to prevent adverse

9186. Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. | PSNet
      psnet.ahrq.gov/issue/linking-acknowledgement-action-closing-loop-non-urgent-clinically-significant-test-results
      July 02, 2019 - Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse … December 31, 2014 Adverse diagnostic events in hospitalised patients: a single-centre … October 16, 2024 Effect of digital tools to promote hospital quality and safety on adverse

9187. How hospital leaders contribute to patient safety through the development of trust. | PSNet
      psnet.ahrq.gov/issue/how-hospital-leaders-contribute-patient-safety-through-development-trust
      January 22, 2014 - January 31, 2013 Variation in detected adverse events using trigger tools: a systematic … December 31, 2012 Occurrence of no-harm incidents and adverse events in hospitalized … October 8, 2013 Impact of organizational culture on preventability assessment of selected adverse

9188. Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. | PSNet
      psnet.ahrq.gov/issue/improving-safety-evaluating-impact-supply-chain-and-drug-shortages-health-systems
      November 04, 2020 - Supply chain vulnerabilities can lead to equipment and drug shortages which can result in adverse … July 8, 2020 The impact of drug error reduction software on preventing harmful adverse … newly implemented commercial computerized provider order-entry system: override appropriateness and adverse

9189. Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. | PSNet
      psnet.ahrq.gov/issue/unsafe-design-infusion-task-reallocation-and-safety-perceptions-us-hospitals
      December 21, 2017 - December 21, 2017 Adverse events and burnout: the moderating effects of workgroup identification … March 8, 2023 Do medical inpatients who report poor service quality experience more adverse … 30, 2021 Burnout and its relationship to self-reported quality of patient care and adverse

9190. A clinical data warehouse-based process for refining medication orders alerts. | PSNet
      psnet.ahrq.gov/issue/clinical-data-warehouse-based-process-refining-medication-orders-alerts
      March 10, 2011 - August 29, 2012 An observational study of adult admissions to a medical ICU due to adverse … March 16, 2016 A systematic review of adult admissions to ICUs related to adverse drug … July 29, 2020 Reducing drug prescription errors and adverse drug events by application

9191. Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. | PSNet
      psnet.ahrq.gov/issue/alternatives-potentially-inappropriate-medications-use-e-prescribing-software-triggers-and
      February 18, 2011 - describes the development of improved alerts and alternate treatment algorithms to reduce the number of adverse … pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse … September 2, 2009 Experience with a trigger tool for identifying adverse drug events

9192. Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization. | PSNet
      psnet.ahrq.gov/issue/technical-evaluation-testing-and-validation-usability-electronic-health-records-empirically
      March 01, 2017 - November 16, 2022 Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced … March 6, 2019 Defense Health Agency Should Improve Tracking of Serious Adverse Medical … Executives and Administrators Information Professionals Medicine Epidemiology of Errors and Adverse

9193. Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke. | PSNet
      psnet.ahrq.gov/issue/identifying-errors-and-safety-considerations-patients-undergoing-thrombolysis-acute-ischemic
      February 09, 2022 - RIS Download Citation Related Resources From the Same Author(s) Adverse … February 9, 2022 Assessing resident and attending error and adverse events in the emergency … March 20, 2017 Occurrence of no-harm incidents and adverse events in hospitalized patients

9194. 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

9195. 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

9196. 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-

9197. 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.

9198. 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

9199. 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

9200. 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