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Total Results: over 10,000 records

Showing results for "event".

181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837593/psn-pdf
     June 29, 2022 - Adverse event reporting priorities: an integrative review. … Adverse event reporting priorities: an integrative review. … https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrative-review Adverse event reporting … This review identified four key priorities in increasing adverse event reporting: understanding and … https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrative-review https://psnet.ahrq.gov

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48156/psn-pdf
     January 01, 2020 - Study of a multisite prospective adverse event surveillance system. … Study of a multisite prospective adverse event surveillance system. … https://psnet.ahrq.gov/issue/study-multisite-prospective-adverse-event-surveillance-system This prospective … among the trigger event reviewers was responsible for some of the variation in observed events. … These results underscore the challenge of accurate adverse event surveillance.

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849129/psn-pdf
     November 01, 2023 - safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event … Safety Trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event … psnet.ahrq.gov/issue/patient-safety-trends-2022-analysis-256679-serious-events-and-incidents- nations-largest-event … The most frequently reported event continues to be Error Related to Procedure/Treatment/Test followed … psnet.ahrq.gov/issue/patient-safety-trends-2022-analysis-256679-serious-events-and-incidents-nations-largest-event

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867521/psn-pdf
     April 01, 2024 - safety trends in 2023: an analysis of 287,997 serious events and incidents from the nation’s largest event … safety trends in 2023: an analysis of 287,997 serious events and incidents from the nation’s largest event … psnet.ahrq.gov/issue/patient-safety-trends-2023-analysis-287997-serious-events-and-incidents- nations-largest-event … The most commonly reported event type were errors related to procedures, tests or treatments (accounting … psnet.ahrq.gov/issue/patient-safety-trends-2023-analysis-287997-serious-events-and-incidents-nations-largest-event

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33592/psn-pdf
     December 15, 2024 - The event was considered adverse but not due to negligence." … The event was considered adverse and due to negligence." … A final subcategory of adverse event is the ameliorable adverse event, a term first coined in a study … (Some studies use the related terms "potential adverse event" and "close call.") … When an adverse event occurred, reviewers also may disagree about whether the event was preventable.

186. Adverse Events, Near Misses, and Errors | PSNet
     psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
     March 30, 2022 - The event was considered adverse but not due to negligence." … The event was considered adverse and due to negligence." … A final subcategory of adverse event is the ameliorable adverse event , a term first coined in a study … (Some studies use the related terms "potential adverse event" and "close call.") … When an adverse event occurred, reviewers also may disagree about whether the event was preventable.

187. Managing the risks of direct oral anticoagulants. | PSNet
     psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
     December 23, 2016 - Sentinel Event Alerts Managing the risks of direct oral anticoagulants. … Sentinel Event Alert. July 30, 2019;(61):1-5. … Facebook Twitter Linkedin Copy URL August 7, 2019 Sentinel Event … Sentinel Event Alert. July 30, 2019;(61):1-5. … December 23, 2016 Sentinel Event Alert.

188. 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 … Improving safety recommendations before implementation: a simulation-based event analysis to optimize … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event- … analysis-optimize Prior research has found that simulation-based event analysis (SBEA) can identify … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event-analysis-optimize

189. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867769/psn-pdf
     March 12, 2025 - Lessons from Event Reports. March 12, 2025 Lessons from Event Reports. Patient Safety Authority. … https://psnet.ahrq.gov/issue/lessons-event-reports Small successes can inform and motivate actions leading … This searchable collection of projects initiated in response to event reports supports the spread of … https://psnet.ahrq.gov/issue/lessons-event-reports https://psnet.ahrq.gov/issue/checklist https://psnet.ahrq.gov

190. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50596/psn-pdf
     October 30, 2019 - Encouraging resident adverse event reporting: a qualitative study of suggestions from the front lines … Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines … https://psnet.ahrq.gov/issue/encouraging-resident-adverse-event-reporting-qualitative-study-suggestions … - front-lines Encouraging adverse event reporting among health care providers, including medical trainees … This qualitative study convened focus groups to elucidate what factors support event reporting among

191. Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians. | PSNet
     psnet.ahrq.gov/issue/use-handheld-computer-application-voluntary-medication-event-reporting-inpatient-nurses-and
     February 16, 2011 - Study Use of a handheld computer application for voluntary medication event reporting … Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and … Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and … used in daily workflow increases adverse event reporting by physicians. … with participation in adverse event reporting.

192. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/847535/psn-pdf
     April 12, 2023 - Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective … Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective … https://psnet.ahrq.gov/issue/using-generic-analysis-method-analyze-sentinel-event-reports-across- hospitals-retrospective … This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing … https://psnet.ahrq.gov/issue/using-generic-analysis-method-analyze-sentinel-event-reports-across-hospitals-retrospective

193. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73291/psn-pdf
     May 19, 2021 - How can never event data be used to reflect or improve hospital safety performance? … How can never event data be used to reflect or improve hospital safety performance? … https://psnet.ahrq.gov/issue/how-can-never-event-data-be-used-reflect-or-improve-hospital-safety- performance … The authors suggest that regulators focus on reducing the national never event rate through shared learning … https://psnet.ahrq.gov/issue/how-can-never-event-data-be-used-reflect-or-improve-hospital-safety-performance

194. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46867/psn-pdf
     February 20, 2019 - Connecting perspectives on quality and safety: patient- level linkage of incident, adverse event and … Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and … psnet.ahrq.gov/issue/connecting-perspectives-quality-and-safety-patient-level-linkage-incident- adverse-event-and … in hospitalized patients are captured in three ways: incident reports (process problems), adverse event … unique problems, but patients with an incident reported were more likely to experience an adverse event

195. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846760/psn-pdf
     March 29, 2023 - Electronic health record-based prediction models for in- hospital adverse drug event diagnosis or prognosis … Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis … https://psnet.ahrq.gov/issue/electronic-health-record-based-prediction-models-hospital-adverse-drug-event … several challenges related to electronic health record (EHR)-based prediction models for adverse drug event … https://psnet.ahrq.gov/issue/electronic-health-record-based-prediction-models-hospital-adverse-drug-event-diagnosis-or

196. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74172/psn-pdf
     December 08, 2021 - Differences in safety report event types submitted by graduate medical education trainees compared with … Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compared With … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education … - trainees-compared Adverse event reporting by health care providers, including medical trainees, is … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education-trainees-compared

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867384/psn-pdf
     December 18, 2024 - Involving patients and/or their next of kin in serious adverse event investigations: a qualitative study … Involving patients and/or their next of kin in serious adverse event investigations: a qualitative study … https://psnet.ahrq.gov/issue/involving-patients-andor-their-next-kin-serious-adverse-event-investigations … https://psnet.ahrq.gov/issue/involving-patients-andor-their-next-kin-serious-adverse-event-investigations-qualitative … https://psnet.ahrq.gov/issue/involving-patients-andor-their-next-kin-serious-adverse-event-investigations-qualitative

198. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841144/psn-pdf
     December 07, 2022 - Using community detection techniques to identify themes in COVID-19-related patient safety event reports … Using community detection techniques to identify themes in COVID-19-related patient safety event reports … psnet.ahrq.gov/issue/using-community-detection-techniques-identify-themes-covid-19-related- patient-safety-event … This study used machine learning to group of more than 2,000 patient safety event (PSE) reports into … https://psnet.ahrq.gov/issue/patient-safety-concerns-covid-19-related-events-study-343-event-reports

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/842770/psn-pdf
     January 18, 2023 - A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic … A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic … https://psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease … but they did observe a relationship between staffing levels during the pandemic and patient safety event … https://psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease

200. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837307/psn-pdf
     June 01, 2022 - Adverse event reviews in healthcare: what matters to patients and their family? … Adverse event reviews in healthcare: what matters to patients and their family? … https://psnet.ahrq.gov/issue/adverse-event-reviews-healthcare-what-matters-patients-and-their-family- … This qualitative study explored the experiences of patients and family members involved in adverse event … outline eight key recommendations to address these themes by involving patients and families in adverse event