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psnet.ahrq.gov/node/43413/psn-pdf
October 20, 2014 - morbidity-and-mortality-conference-adverse-event-surveillance-tool-paediatric-
intensive-care
In this study, applying standardized chart … Conversely, the conferences revealed near misses and diagnostic errors that were not obvious in chart
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psnet.ahrq.gov/node/34673/psn-pdf
December 23, 2008 - Medication errors
were identified by self-report, nurse chart review, and medication sheet review. … Adverse drug events
(ADEs) or potential ADEs were identified by spontaneous reporting and daily chart
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psnet.ahrq.gov/issue/time-out-charting-path-improving-performance-measurement
March 06, 2005 - Commentary
Classic
Time out—charting a path for improving performance measurement.
Citation Text:
MacLean CH, Kerr EA, Qaseem A. Time Out - Charting a Path for Improving Performance Measurement. N Engl J Med. 2018;378(19):1757-1761. doi:10.1056/NEJMp1802595.
C…
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psnet.ahrq.gov/issue/comparison-accuracy-physical-examination-findings-initial-progress-notes-between-paper-charts
May 11, 2022 - Comparison of accuracy of physical examination findings in initial progress notes between paper charts … Comparison of accuracy of physical examination findings in initial progress notes between paper charts … Compared to paper charts, electronic health records offer safety benefits for physician documentation … Investigators found more inaccuracies in electronic notes, but more errors of omission in paper charts … Comparison of accuracy of physical examination findings in initial progress notes between paper charts
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psnet.ahrq.gov/issue/applied-use-safety-event-occurrence-control-charts-harm-and-non-harm-events-case-study
October 23, 2024 - Commentary
Applied use of safety event occurrence control charts of harm and non-harm … Applied Use of Safety Event Occurrence Control Charts of Harm and Non-Harm Events: A Case Study. … Applied Use of Safety Event Occurrence Control Charts of Harm and Non-Harm Events: A Case Study.
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psnet.ahrq.gov/issue/reducing-emergency-department-charting-and-ordering-errors-room-number-watermark-electronic
November 22, 2017 - This survey found that physicians chart or write orders in the wrong patient's electronic health record
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psnet.ahrq.gov/node/36308/psn-pdf
January 05, 2017 - trigger-tool-identify-adverse-events-intensive-care-unit
This study describes the use of a focused chart … Non-physician reviewers at 54 hospitals screened charts for
evidence of 23 clinical events, such as … If any of these triggers were present, the relevant portion of the chart was
reviewed using methodology
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psnet.ahrq.gov/issue/high-priority-drug-drug-interaction-clinical-decision-support-overrides-newly-implemented
March 09, 2022 - that nearly 96% were overridden by providers; of these overrides, 45.4% were deemed appropriate upon chart … Alerts for high-priority drug-drug interactions were overridden 87% of the time, and chart review determined
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psnet.ahrq.gov/node/46436/psn-pdf
May 30, 2018 - Effect of number of open charts on intercepted wrong-
patient medication orders in an emergency department … Effect of number of open charts on intercepted wrong-
patient medication orders in an emergency department … https://psnet.ahrq.gov/issue/effect-number-open-charts-intercepted-wrong-patient-medication-orders- … emergency-department
Opening multiple patients' charts in the electronic medical record simultaneously … Similarly,
there was no significant increase when the maximum number of charts permitted to be open
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psnet.ahrq.gov/issue/emergency-medical-services-provider-pediatric-adverse-event-rate-varies-call-origin-pediatric
November 23, 2016 - November 23, 2016
Out-of-hospital pediatric patient safety events: results of the CSI chart … January 31, 2024
Reliability and usability of a 7-minute chart review tool to identify … Related Resources
Out-of-hospital pediatric patient safety events: results of the CSI chart
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psnet.ahrq.gov/node/36366/psn-pdf
April 11, 2011 - study used methodology similar to a prior study in adult
intensive care unit patients to develop a chart-based … Through an expert consensus process, 17 triggers were identified and used to
screen charts from 15 NICUs … Use of this chart-based review process may help identify specific patient
populations at high risk for
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psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-events-hospitalized-patients
May 27, 2011 - , and ADEs were determined by solicited reporting by nurses and pharmacists, as well as independent chart … The authors found that 67% of the ADEs were identified only by chart review and not by solicited reporting
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - I picked up the chart that was next to this patient. The chart was correct for my next patient. … certified nurse anesthetist checked the patient's wristband and alerted the nurse to her error—the chart … was placed by the patient’s bedside; second, the RN did not question that the chart could be incorrect … Apparently, the nurse read the information from the wrong chart and the patient, in her anxiety, confirmed … the wrong patient is about to be taken for a procedure, she may still have the correct wristband and chart
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - I picked up the chart that
was next to this patient. The chart was correct for my next patient. … certified nurse anesthetist checked the patient's wristband
and alerted the nurse to her error—the chart … confluence of several errors, each of which may seem
relatively minor itself: first, the wrong patient chart … was placed by the patient’s bedside; second, the RN did
not question that the chart could be incorrect … Apparently, the nurse read the information from
the wrong chart and the patient, in her anxiety, confirmed
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psnet.ahrq.gov/node/35281/psn-pdf
March 11, 2011 - Detection and prevention of medication errors using real-
time bedside nurse charting.
March 11, 2011
Nelson NC, Evans RS, Samore MH, et al. Detection and Prevention of Medication Errors Using Real-Time
Bedside Nurse Charting. Journal of the American Medical Informatics Association. 2005;12(4).
doi:10.1197/jamia.m…
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psnet.ahrq.gov/issue/effect-medication-errors-pharmacists-charting-medication-emergency-department
November 16, 2022 - Study
The effect on medication errors of pharmacists charting medication in an emergency department.
Citation Text:
Vasileff HM, Whitten LE, Pink JA, et al. The effect on medication errors of pharmacists charting medication in an emergency department. Pharm World Sci. 2009;31(3):373-9.…
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psnet.ahrq.gov/node/44826/psn-pdf
February 14, 2017 - validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-
centers
The ability to use administrative data to measure patient safety is critical, because chart … This systematic review found that PSIs and HACs have not been adequately validated
compared to chart
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psnet.ahrq.gov/node/44630/psn-pdf
February 15, 2017 - Reduction of incorrect record accessing and charting
patient electronic medical records in the perioperative
environment.
February 15, 2017
Rebello E, Kee S, Kowalski A, et al. Reduction of incorrect record accessing and charting patient electronic
medical records in the perioperative environment. Health Informati…
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psnet.ahrq.gov/issue/morbidity-and-mortality-conference-adverse-event-surveillance-tool-paediatric-intensive-care
April 06, 2016 - In this study, applying standardized chart reviews for incidents discussed during morbidity and mortality … Conversely, the conferences revealed near misses and diagnostic errors that were not obvious in chart
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psnet.ahrq.gov/node/837759/psn-pdf
January 01, 2023 - Employee silence in health care: charting new avenues
for leadership and management.
August 3, 2022
Montgomery A, Lainidi O, Johnson J, et al. Employee silence in health care: Charting new avenues for
leadership and management. Health Care Manage Rev. 2023;48(1):52-60.
doi:10.1097/hmr.0000000000000349.
https://ps…