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Total Results: 5,203 records

Showing results for "deaths".

  1. The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety. | PSNet

    psnet.ahrq.gov/issue/devil-detail-how-closed-loop-documentation-system-iv-infusion-administration-contributes-and
    February 12, 2020 - Study The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety. Citation Text: Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation system for IV infusi…

  2. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. | PSNet

    psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
    June 24, 2020 - Study Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. Citation Text: Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…

  3. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. | PSNet

    psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
    November 16, 2022 - Study Classic Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Citation Text: Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…

  4. The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study. | PSNet

    psnet.ahrq.gov/issue/expanding-role-antimicrobial-stewardship-programs-hospitals-united-states-lessons-learned
    March 04, 2015 - Study The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study. Citation Text: Kapadia SN, Abramson EL, Carter EJ, et al. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the Uni…

  5. Patients' perception of types of errors in palliative care—results from a qualitative interview study. | PSNet

    psnet.ahrq.gov/issue/patients-perception-types-errors-palliative-care-results-qualitative-interview-study
    December 04, 2016 - Study Patients' perception of types of errors in palliative care—results from a qualitative interview study. Citation Text: Kiesewetter I, Schulz CM, Bausewein C, et al. Patients' perception of types of errors in palliative care - results from a qualitative interview study. BMC Palliat C…

  6. Safety in pediatric hospice and palliative care: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/safety-pediatric-hospice-and-palliative-care-qualitative-study
    September 02, 2020 - Study Safety in pediatric hospice and palliative care: a qualitative study. Citation Text: Pestian T, Thienprayoon R, Grossoehme D, et al. Safety in pediatric hospice and palliative care: a qualitative study. Pediatr Qual Saf. 2020;5(4):e328. doi:10.1097/pq9.0000000000000328. Copy Cit…

  7. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. | PSNet

    psnet.ahrq.gov/issue/errors-administration-parenteral-drugs-intensive-care-units-multinational-prospective-study
    September 30, 2010 - Study Errors in administration of parenteral drugs in intensive care units: multinational prospective study. Citation Text: Valentin A, Capuzzo M, Guidet B, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.…

  8. Structuring patient and family involvement in medical error event disclosure and analysis. | PSNet

    psnet.ahrq.gov/issue/structuring-patient-and-family-involvement-medical-error-event-disclosure-and-analysis
    September 01, 2018 - Study Structuring patient and family involvement in medical error event disclosure and analysis. Citation Text: Etchegaray J, Ottosen M, Burress L, et al. Structuring patient and family involvement in medical error event disclosure and analysis. Health Aff (Millwood). 2014;33(1):46-52. d…

  9. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. | PSNet

    psnet.ahrq.gov/issue/barriers-and-success-factors-implementation-multi-site-prospective-adverse-event-surveillance
    November 15, 2017 - Study Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Citation Text: Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Int…

  10. Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations. | PSNet

    psnet.ahrq.gov/issue/quality-measures-patients-risk-adverse-outcomes-veterans-health-administration-expert-panel
    June 22, 2022 - Commentary Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations. Citation Text: Chang ET, Newberry S, Rubenstein LV, et al. Quality Measures for Patients at Risk of Adverse Outcomes in the Veterans Health Administra…

  11. New persistent opioid use after postoperative intensive care in US veterans. | PSNet

    psnet.ahrq.gov/issue/new-persistent-opioid-use-after-postoperative-intensive-care-us-veterans
    July 10, 2024 - Study New persistent opioid use after postoperative intensive care in US veterans. Citation Text: Karamchandani K, Pyati S, Bryan W, et al. New Persistent Opioid Use After Postoperative Intensive Care in US Veterans. JAMA Surg. 2019;154(8):778-780. doi:10.1001/jamasurg.2019.0899. Copy …

  12. Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study. | PSNet

    psnet.ahrq.gov/issue/effects-night-surgery-postoperative-mortality-and-morbidity-multicentre-cohort-study
    July 19, 2019 - Study Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study. Citation Text: Althoff FC, Wachtendorf LJ, Rostin P, et al. Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study. BMJ Qual Saf. 2020;30(8):678-688…

  13. Evaluating the effect of data standardization and validation on patient matching accuracy. | PSNet

    psnet.ahrq.gov/issue/evaluating-effect-data-standardization-and-validation-patient-matching-accuracy
    November 28, 2018 - Study Evaluating the effect of data standardization and validation on patient matching accuracy. Citation Text: Grannis SJ, Xu H, Vest JR, et al. Evaluating the effect of data standardization and validation on patient matching accuracy. J Am Med Inform Assoc. 2019;26(5):447-456. doi:10.1…

  14. Interpersonal and organizational dynamics are key drivers of failure to rescue. | PSNet

    psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue
    June 18, 2019 - Study Interpersonal and organizational dynamics are key drivers of failure to rescue. Citation Text: Smith ME, Wells EE, Friese CR, et al. Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. Health Aff (Millwood). 2018;37(11):1870-1876. doi:10.1377/hlthaff.201…

  15. Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. | PSNet

    psnet.ahrq.gov/issue/failure-rescue-following-emergency-surgery-fram-analysis-management-deteriorating-patient
    May 19, 2021 - Study Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. Citation Text: Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient. Appl Ergon.…

  16. What methods are used to apply positive deviance within healthcare organisations? A systematic review. | PSNet

    psnet.ahrq.gov/issue/what-methods-are-used-apply-positive-deviance-within-healthcare-organisations-systematic
    July 19, 2019 - Review What methods are used to apply positive deviance within healthcare organisations? A systematic review. Citation Text: Baxter R, Taylor N, Kellar I, et al. What methods are used to apply positive deviance within healthcare organisations? A systematic review. BMJ Qual Saf. 2016;25(3…

  17. The benefits of health information technology: a review of the recent literature shows predominantly positive results. | PSNet

    psnet.ahrq.gov/issue/benefits-health-information-technology-review-recent-literature-shows-predominantly-positive
    December 21, 2018 - Review Classic The benefits of health information technology: a review of the recent literature shows predominantly positive results. Citation Text: Buntin MB, Burke MF, Hoaglin MC, et al. The Benefits Of Health Information Technology: A Review Of The Recent Lit…

  18. A framework to assess patient-reported adverse outcomes arising during hospitalization. | PSNet

    psnet.ahrq.gov/issue/framework-assess-patient-reported-adverse-outcomes-arising-during-hospitalization
    December 06, 2017 - Study A framework to assess patient-reported adverse outcomes arising during hospitalization. Citation Text: Okoniewska B, Santana MJ, Holroyd-Leduc J, et al. A framework to assess patient-reported adverse outcomes arising during hospitalization. BMC Health Serv Res. 2016;16(a):357. doi:…

  19. Why and how to approach user experience in safety-critical domains: the example of health care. | PSNet

    psnet.ahrq.gov/issue/why-and-how-approach-user-experience-safety-critical-domains-example-health-care
    May 05, 2021 - Commentary Why and how to approach user experience in safety-critical domains: the example of health care. Citation Text: Grundgeiger T, Hurtienne J, Happel O. Why and how to approach user experience in safety-critical domains: the example of health care. Hum Factors. 2020;63(5):821-832.…

  20. Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness. | PSNet

    psnet.ahrq.gov/issue/analysis-academic-medical-centers-corrective-action-plan-response-fatal-medication-error
    February 21, 2018 - Commentary Analysis of an academic medical center’s corrective action plan in response to fatal medication error using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness. Citation Text: Stolte AR, Siwy YM, Tanios SB, et al. Analysis of an academic medical center’s co…
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