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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45021/psn-pdf
    April 06, 2016 - Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. April 6, 2016 Bloche G. … Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. … https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs Latent … https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs https:
  2. 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. … https://psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysis-deaths-surgical-care This … https://psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysis-deaths-surgical-care https
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45613/psn-pdf
    September 01, 2018 - https://psnet.ahrq.gov/issue/patients-partners-learning-unexpected-events Adverse event investigation … In this study, investigators interviewed patients and family members following an adverse event to determine … However, the majority of participants were not involved in root cause analysis or other formal event … The authors conclude that patient perspectives should be included in event analysis.
  4. psnet.ahrq.gov/web-mm/departure-central-line-ritual
    October 13, 2018 - (pre-event, event, post-event) and the contributing agents of each phase (personal attribute, vector … However, even in the operative setting, guidewire retention is not a never event.( 9 ) The literature … Here, a clear opportunity for intra-event error recognition was lost. … In the case of CVC guidewire retention, post-event interventions center on early recognition. … to post-event continuum.
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38026/psn-pdf
    March 21, 2017 - Does error and adverse event reporting by physicians and nurses differ? … Does error and adverse event reporting by physicians and nurses differ? … https://psnet.ahrq.gov/issue/does-error-and-adverse-event-reporting-physicians-and-nurses-differ Hospital … https://psnet.ahrq.gov/issue/does-error-and-adverse-event-reporting-physicians-and-nurses-differ https
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41030/psn-pdf
    March 04, 2015 - A systematic review to evaluate the accuracy of electronic adverse drug event detection. … A systematic review to evaluate the accuracy of electronic adverse drug event detection. … https://psnet.ahrq.gov/issue/systematic-review-evaluate-accuracy-electronic-adverse-drug-event-detection … https://psnet.ahrq.gov/issue/systematic-review-evaluate-accuracy-electronic-adverse-drug-event-detection
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39673/psn-pdf
    December 21, 2014 - Effect of hospital follow-up appointment on clinical event outcomes and mortality. … Effect of hospital follow-up appointment on clinical event outcomes and mortality. … https://psnet.ahrq.gov/issue/effect-hospital-follow-appointment-clinical-event-outcomes-and-mortality … https://psnet.ahrq.gov/issue/effect-hospital-follow-appointment-clinical-event-outcomes-and-mortality
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37447/psn-pdf
    January 09, 2008 - No pay for "never event" errors becoming standard. January 9, 2008 O'Reilly KB. … https://psnet.ahrq.gov/issue/no-pay-never-event-errors-becoming-standard This article discusses the … https://psnet.ahrq.gov/issue/no-pay-never-event-errors-becoming-standard https://psnet.ahrq.gov/issue
  9. psnet.ahrq.gov/training-catalog/webinar-series-0
    Organization American Medical Association (AMA) EventEvent Location: Online Date: On demand Event Fee: Fee Associated CE or CME Offered?
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43254/psn-pdf
    May 01, 2015 - a 7-year period, this study found that nearly 1 in 5 older adults experienced at least one adverse event … Patients who experienced an adverse medical event had much higher mortality rates, though it should … Medicare expenditures increased sharply during an adverse medical event episode and remained high following … the event.
  11. psnet.ahrq.gov/training-catalog/safetyleaders-home
    Organization: Organization SafetyLeaders EventEvent Location: Online Date: On demand Event Fee: Free CE or CME Offered?
  12. psnet.ahrq.gov/training-catalog/monthly-webinars
    Organization: Organization Quality Reporting Center EventEvent Location: Online Date: On demand Event Fee: Free CE or CME Offered?
  13. psnet.ahrq.gov/training-catalog/armstrong-institute-training-catalog
    Johns Hopkins Armstrong Institute for Patient Safety and Quality Event … Description: Collection of patient safety training modules Event Location: Online Date: … On demand Event Fee: Fee Associated CE or CME Offered?
  14. psnet.ahrq.gov/training-catalog/webinar-series-3
    Organization: Organization Hospital Quality Institute EventEvent Location: Online Date: On demand Event Fee: Free CE or CME Offered?
  15. psnet.ahrq.gov/training-catalog/webinar-series
    Organization: Organization Patient Safety Authority EventEvent Location: Online Date: Various dates Event Fee: Free CE or CME Offered?
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38308/psn-pdf
    April 21, 2010 - Adverse-event-reporting practices by US hospitals: results of a national survey. … Adverse-event-reporting practices by US hospitals: results of a national survey. … https://psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey … https://psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey https
  17. psnet.ahrq.gov/training-catalog/ashp-learning-center
    Organization American Society for Health-System Pharmacists (ASHP) EventEvent Location: Online Date: On demand Event Fee: Fee Associated (for some) CE or CME Offered
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39736/psn-pdf
    April 03, 2017 - Risk and Event Assessment. April 3, 2017 Jt Comm J Qual Patient Saf. 2010;36:348-385. … https://psnet.ahrq.gov/issue/risk-and-event-assessment This issue contains several articles dedicated … https://psnet.ahrq.gov/issue/risk-and-event-assessment https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its
  19. psnet.ahrq.gov/training-catalog/pharmacy-education-opportunities
    Organization National Community Pharmacists Association (NCPA) EventEvent Location: Online Date: On demand Event Fee: Fee Associated CE or CME Offered?
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40038/psn-pdf
    December 23, 2016 - Sentinel Event Alert. 2010;46(46):1-4. … follow-report-preventing-suicide-focus-medicalsurgical-units-and-emergency- department Suicide among hospitalized patients remains an under-recognized never event … This Sentinel Event Alert reviews risk factors for inpatient suicide and delineates prevention strategies … never-events https://psnet.ahrq.gov/issue/suicide-medical-setting https://psnet.ahrq.gov/issue/sentinel-event-alert

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