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Showing results for "adverse event".
Users also searched for: patient safety indicators

  1. The pursuit of better diagnostic performance: a human factors perspective. | PSNet

    psnet.ahrq.gov/issue/pursuit-better-diagnostic-performance-human-factors-perspective
    September 24, 2017 - April 8, 2018 Advancing medication safety: establishing a National Action Plan for Adverse … Drug Event Prevention.

  2. Preventing errors when preparing and administering medications via enteral feeding tubes. | PSNet

    psnet.ahrq.gov/issue/preventing-errors-when-preparing-and-administering-medications-enteral-feeding-tubes
    November 30, 2016 - March 29, 2023 Latent and active failures perfectly align to allow a preventable adverse … event to reach a patient.

  3. Broken Trust: Making Patient Safety More than Just a Promise. | PSNet

    psnet.ahrq.gov/issue/broken-trust-making-patient-safety-more-just-promise
    October 07, 2020 - Ensuring sufficient patient notification efforts after a large-scale adverse event.

  4. Creating a Safe Medicine List: Patient Information/Reminder Flyer (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-patient-flier-final508.pdf
    June 02, 2025 - . ■ Answer your questions. 1 in 9 emergency department admissions are related to an adverse drug … event.

  5. Physician liability in the age of data reliance and errors. | PSNet

    psnet.ahrq.gov/issue/physician-liability-age-data-reliance-and-errors
    March 18, 2020 - August 26, 2020 The confused and bewildered hospital: adverse event discovery, pay-for-performance

  6. Preventing health care–associated harm in children. | PSNet

    psnet.ahrq.gov/issue/preventing-health-care-associated-harm-children
    March 14, 2022 - November 16, 2022 Families as partners in hospital error and adverse event surveillance

  7. Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work. | PSNet

    psnet.ahrq.gov/issue/discovering-healthcare-cognition-use-cognitive-artifacts-reveal-cognitive-work
    October 10, 2010 - October 3, 2011 Families as partners in hospital error and adverse event surveillance

  8. Surgical fires, a clear and present danger. | PSNet

    psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger
    May 16, 2018 - September 2, 2020 Families as partners in hospital error and adverse event surveillance

  9. Wide heart monitor use tied to missed alarms. | PSNet

    psnet.ahrq.gov/issue/wide-heart-monitor-use-tied-missed-alarms
    July 19, 2023 - July 19, 2023 Families as partners in hospital error and adverse event surveillance.

  10. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. | PSNet

    psnet.ahrq.gov/issue/defensive-medicine-among-high-risk-specialist-physicians-volatile-malpractice-environment
    February 17, 2011 - An analysis of adverse event costs, the medical liability system, and incentives for patient safety improvement

  11. Medical overuse as a physician cognitive error: looking under the hood. | PSNet

    psnet.ahrq.gov/issue/medical-overuse-physician-cognitive-error-looking-under-hood
    September 25, 2019 - September 15, 2021 Reporting of death in US Food and Drug Administration medical device adverse … event reports in categories other than death.

  12. Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. | PSNet

    psnet.ahrq.gov/issue/survey-shows-room-improvement-two-new-ismp-targeted-medication-safety-best-practices
    February 12, 2020 - February 28, 2024 Latent and active failures perfectly align to allow a preventable adverse … event to reach a patient.

  13. Bar-code verification: reducing but not eliminating medication errors. | PSNet

    psnet.ahrq.gov/issue/bar-code-verification-reducing-not-eliminating-medication-errors
    September 27, 2016 - October 19, 2022 Families as partners in hospital error and adverse event surveillance

  14. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. | PSNet

    psnet.ahrq.gov/issue/handoff-checklists-improve-reliability-patient-handoffs-operating-room-and-postanesthesia
    December 29, 2014 - June 23, 2021 WebM&M Cases Adverse Event During Intrahospital

  15. Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report. | PSNet

    psnet.ahrq.gov/issue/cultural-issues-related-allegations-bullying-and-harassment-nhs-highland-independent-review
    July 29, 2015 - August 23, 2017 Critical Incident Reviews, Significant Adverse Event Reports and Action

  16. 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-

  17. 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.

  18. 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

  19. 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

  20. 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
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