Results

Total Results: over 10,000 records

Showing results for "event".

9821. 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…

9822. 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 …

9823. 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…

9824. 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…

9825. 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…

9826. 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…

9827. 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

9828. High-Risk Medications, High-Risk Transfers | PSNet
      psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
      December 21, 2017 - High-Risk Medications, High-Risk Transfers Citation Text: Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote …

9829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47594/psn-pdf
      March 17, 2023 - Prevention of perioperative medication errors. March 17, 2023 Nanji K. UpToDate. March 7, 2023. https://psnet.ahrq.gov/issue/prevention-perioperative-medication-errors Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical …

9830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37972/psn-pdf
      May 02, 2018 - Heparin errors continue despite prior, high-profile, fatal events. May 2, 2018 ISMP Medication Safety Alert! Acute Care Edition. July 17, 2008;13:1-2. https://psnet.ahrq.gov/issue/heparin-errors-continue-despite-prior-high-profile-fatal-events Drawing on analysis from previously reported errors, this article descr…

9831. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-402
      August 30, 2023 - Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event … Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

9832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861880/psn-pdf
      January 31, 2024 - Effect of patient and family centered I-PASS on adverse event rates in hospitalized children with complex … Sentinel event statistics released for 2014. Jt Comm Online. 2015.

9833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49468/psn-pdf
      December 16, 2004 - Since 1998, when the Joint Commission issued its first Sentinel Event Alert on wrong-site surgery (1,2 … Sentinel event alert. Lessons learned: wrong site surgery. … Sentinel event alert. A follow-up review of wrong site surgery. … /sentinel-event-alert-newsletters/sentinel-event-alert-issue-6-lessons-learned-wrong-site-surgery/ https … ://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters

9834. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - all efforts should be made to get patients, families, and providers on the same page before an acute event … August 17, 2017 WebM&M Cases Adverse Event During Intrahospital

9835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49639/psn-pdf
      November 01, 2011 - Thus, a common definition of a near miss is "An event or a situation that did not produce patient harm … In fact, capturing every adverse event or near miss can be overwhelming and may be undesirable, as in

9836. Innovations | PSNet
      psnet.ahrq.gov/innovations
      February 26, 2025 - Information Systems (11) Electronic Health Records (8) Computerized Adverse Event … Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling January 31, 2024 Save

9837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49600/psn-pdf
      April 01, 2010 - bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event … Council on Medication Error Reporting and Prevention defines a medication error as "any preventable event

9838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842923/psn-pdf
      February 01, 2023 - appropriately included an environmental assessment of all hospital areas pertaining to the case.16For this event … Equipment & Materials Finally, an event of this type provides an opportunity to evaluate scheduled protocols

9839. Inappropriate Antibiotic Use | PSNet
      psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
      September 22, 2010 - References Related Resources From the Same Author(s) A new safety event … September 22, 2010 Patient safety event reporting in critical care: a study of three

9840. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
      January 01, 2024 - /Systems Learning (1) • A growth mindset should prevail when analyzing the response to an adverse event … effectiveness of response with as many health care personnel as possible who were involved in the event