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Showing results for "event".

9741. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45207/psn-pdf
      August 17, 2016 - Unit-based incident reporting and root cause analysis: variation at three hospital unit types. August 17, 2016 Wagner C, Merten H, Zwaan L, et al. Unit-based incident reporting and root cause analysis: variation at three hospital unit types. BMJ Open. 2016;6(6):e011277. doi:10.1136/bmjopen-2016-011277. https://psn…

9742. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38611/psn-pdf
      February 15, 2011 - Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. February 15, 2011 Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug …

9743. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47102/psn-pdf
      June 26, 2018 - Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system. June 26, 2018 Whalen K, Lynch E, Moawad I, et al. Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a l…

9744. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46667/psn-pdf
      February 22, 2018 - Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care. February 22, 2018 Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary car…

9745. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46173/psn-pdf
      August 20, 2018 - Advances in Patient Safety and Medical Liability. August 20, 2018 Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF. https://psnet.ahrq.gov/issue/advances-patient-safety-and-medical-liability This publication describes the re…

9746. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60348/psn-pdf
      May 20, 2020 - High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events. May 20, 2020 Edrees H, Amato MG, Wong A, et al. High-priority drug-drug interaction clinical decision support overrid…

9747. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-386
      April 26, 2023 - Study Using the Generic Analysis Method to analyze sentinel event reports across … This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing

9748. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49475/psn-pdf
      March 01, 2005 - Source of New Failures Just a few years ago, prior to development of digital radiology, this type of event … The source of this event is not human error on the part of the surgeon.

9749. ASHP Learning Center | PSNet
      psnet.ahrq.gov/training-catalog/ashp-learning-center
      Organization American Society for Health-System Pharmacists (ASHP) Event … Event Location: Online Date: On demand Event Fee: Fee Associated (for some) CE or CME Offered

9750. 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

9751. Pharmacy Education Opportunities | PSNet
      psnet.ahrq.gov/training-catalog/pharmacy-education-opportunities
      Organization National Community Pharmacists Association (NCPA) Event … Event Location: Online Date: On demand Event Fee: Fee Associated CE or CME Offered?

9752. The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events. | PSNet
      psnet.ahrq.gov/issue/impact-standardized-incident-reporting-system-perioperative-setting-single-center-experience
      February 09, 2022 - Study The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events. Citation Text: Heideveld-Chevalking AJ, Calsbeek H, Damen J, et al. The impact of a standardized incident reporting system in t…

9753. ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome. | PSNet
      psnet.ahrq.gov/issue/icu-admittance-rapid-response-team-versus-conventional-admittance-characteristics-and-outcome
      January 28, 2010 - Study ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome. Citation Text: Jäderling G, Bell M, Martling C-R, et al. ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome. Crit Care Med. 2013…

9754. Enteral nutrition: an underappreciated source of patient safety events. | PSNet
      psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
      February 01, 2023 - Study Enteral nutrition: an underappreciated source of patient safety events. Citation Text: Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events. Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153. Copy Citation Format: …

9755. Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a STAT central laboratory. | PSNet
      psnet.ahrq.gov/issue/use-quality-indicators-compare-point-care-testing-errors-neonatal-unit-and-errors-stat
      December 02, 2020 - Study Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a STAT central laboratory. Citation Text: Cantero M, Redondo M, Martín E, et al. Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a S…

9756. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. | PSNet
      psnet.ahrq.gov/issue/learning-preventable-deaths-exploring-case-record-reviewers-narratives-using-change-analysis
      June 17, 2014 - Study Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. Citation Text: Hogan H, Healey F, Neale G, et al. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. J R Soc Med. 2014;107(9):365-7…

9757. Adverse drug events caused by serious medication administration errors. | PSNet
      psnet.ahrq.gov/issue/adverse-drug-events-caused-serious-medication-administration-errors
      December 19, 2009 - Study Adverse drug events caused by serious medication administration errors. Citation Text: Kale A, Keohane C, Maviglia SM, et al. Adverse drug events caused by serious medication administration errors. BMJ Qual Saf. 2012;21(11):933-8. doi:10.1136/bmjqs-2012-000946. Copy Citation …

9758. Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review. | PSNet
      psnet.ahrq.gov/issue/medicines-related-problems-mrps-originating-primary-care-settings-older-adults-systematic
      March 04, 2015 - Review Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review. Citation Text: Ude-Okeleke RC, Aslanpour Z, Dhillon S, et al. Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review.…

9759. The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. | PSNet
      psnet.ahrq.gov/issue/effect-prescriber-education-medication-related-patient-harm-hospital-systematic-review
      January 07, 2015 - Review The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. Citation Text: Bos JM, van den Bemt PMLA, de Smet PAGM, et al. The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. Br…

9760. Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes. | PSNet
      psnet.ahrq.gov/issue/meaningful-use-stage-2-e-prescribing-threshold-and-adverse-drug-events-medicare-part-d
      July 05, 2017 - Study Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes. Citation Text: Powers C, Gabriel MH, Encinosa W, et al. Meaningful use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population w…