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Showing results for "event".

9961. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient | PSNet
      psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
      October 04, 2023 - a result, inadvertent dose stacking and opioid polypharmacy may have contributed to this mortality event … December 7, 2022 10,000 good catches: increasing safety event reporting in a pediatric

9962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44132/psn-pdf
      May 13, 2015 - Adverse outcomes: why bad things happen to good people. May 13, 2015 Sonnenberg A. Adverse outcomes: why bad things happen to good people. Clin Gastroenterol Hepatol. 2015;13(5):820-3.e1. doi:10.1016/j.cgh.2014.07.064. https://psnet.ahrq.gov/issue/adverse-outcomes-why-bad-things-happen-good-people This commentary…

9963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866164/psn-pdf
      June 19, 2024 - What is the effectiveness of reporting systems in promoting learning in healthcare? June 19, 2024 Sehgal A. What is the effectiveness of reporting systems in promoting learning in healthcare? Br J Hosp Med (Lond). 2024;85(4):1-9. doi:10.12968/hmed.2023.0444. https://psnet.ahrq.gov/issue/what-effectiveness-reportin…

9964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43677/psn-pdf
      November 19, 2014 - Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres. November 19, 2014 Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October 2014. ISBN: 9789241507943. https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…

9965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42913/psn-pdf
      January 29, 2014 - What to do with healthcare incident reporting systems. January 29, 2014 Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems. J Public Health Res. 2013;2(3). doi:10.4081/jphr.2013.e27. https://psnet.ahrq.gov/issue/what-do-healthcare-incident-reporting-systems Incident reporting sy…

9966. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46144/psn-pdf
      June 28, 2017 - Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care. June 28, 2017 Sharma M, Krishnamurthy M, Snyder R, et al. Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care. Clin Pract. 2017;7(2). doi:10.4081/cp.2017.953. https://psnet.ahrq.gov/…

9967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43317/psn-pdf
      July 02, 2014 - More than 750 hospitals face Medicare crackdown on patient injuries. July 2, 2014 Rau J. Kaiser Health News. June 22, 2014. https://psnet.ahrq.gov/issue/more-750-hospitals-face-medicare-crackdown-patient-injuries Financial incentives have shown both benefits and limitations in driving efforts to improve patient sa…

9968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837747/psn-pdf
      July 27, 2022 - Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events. July 27, 2022 Rockville, MD: Agency for Healthcare Research and Quality; July 2022.  AHRQ Publication No. 22- 0038. https://psnet.ahrq.gov/issue/measure-dx-resource-identify-analyze-and-learn-diagnostic-safety-events Diagno…

9969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844551/psn-pdf
      February 15, 2023 - Emotional safety is patient safety. February 15, 2023 Lyndon A, Davis D-A, Sharma AE, et al. Emotional safety is patient safety. BMJ Qual Saf. 2023;32(7):369- 372. doi:10.1136/bmjqs-2022-015573. https://psnet.ahrq.gov/issue/emotional-safety-patient-safety Patient perspectives can provide unique insights into care …

9970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73631/psn-pdf
      August 25, 2021 - Patient harm from cardiovascular medications. August 25, 2021 Paradissis C, Cottrell N, Coombes ID, et al. Patient harm from cardiovascular medications. Ther Adv Drug Saf. 2021;12:204209862110274. doi:10.1177/20420986211027451. https://psnet.ahrq.gov/issue/patient-harm-cardiovascular-medications Adverse drug event…

9971. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. | PSNet
      psnet.ahrq.gov/issue/iatroref-study-medical-errors-are-associated-symptoms-depression-icu-staff-not-burnout-or
      April 12, 2011 - Study The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Citation Text: Garrouste-Orgeas M, Perrin M, Soufir L, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but…

9972. Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. | PSNet
      psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
      May 01, 2015 - Book/Report Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Citation Text: Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Washington, DC: VA Office o…

9973. The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. | PSNet
      psnet.ahrq.gov/issue/national-cost-adverse-drug-events-resulting-inappropriate-medication-related-alert-overrides
      July 02, 2019 - Study The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. Citation Text: Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate medication-related alert override…

9974. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-295
      June 30, 2021 - support programs can help clinicians cope with the emotional consequences of involvement in an adverse event … Wrong-site surgery in dentistry is a frequent and persistent never event.

9975. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-300
      July 28, 2021 - set of specialties and included other healthcare professionals whose disciplines were involved in the event … set of specialties and included other healthcare professionals whose disciplines were involved in the event

9976. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-430
      March 27, 2024 - providers explored near-miss events where taking extra time during patient visits can avoid a more serious event … providers explored near-miss events where taking extra time during patient visits can avoid a more serious event

9977. At risk care plans: a way to reduce readmissions and adverse events. | PSNet
      psnet.ahrq.gov/issue/risk-care-plans-way-reduce-readmissions-and-adverse-events
      October 27, 2010 - Commentary At risk care plans: a way to reduce readmissions and adverse events. Citation Text: Bahle J, Majercik C, Ludwick R, et al. At Risk Care Plans: a way to reduce readmissions and adverse events. J Nurs Care Qual. 2015;30(3):200-4. doi:10.1097/NCQ.0000000000000106. Copy Citation…

9978. Patient safety and quality improvement: an overview of QI. | PSNet
      psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-overview-qi
      November 08, 2023 - Commentary Patient safety and quality improvement: an overview of QI. Citation Text: Schriefer J, Leonard M. Patient safety and quality improvement: an overview of QI. Pediatr Rev. 2012;33(8):353-9; quiz 359-60. doi:10.1542/pir.33-8-353. Copy Citation Format: DOI Google Sc…

9979. Creating a just culture: the Ottawa Hospital's experience. | PSNet
      psnet.ahrq.gov/issue/creating-just-culture-ottawa-hospitals-experience
      July 10, 2024 - Commentary Creating a just culture: the Ottawa Hospital's experience. Citation Text: Forster AJ, Hamilton S, Hayes T, et al. Creating a Just Culture: The Ottawa Hospital's experience. Healthc Manage Forum. 2019;32(5):266-271. doi:10.1177/0840470419853303. Copy Citation Format: …

9980. Medical error, incident investigation and the second victim: doing better but feeling worse? | PSNet
      psnet.ahrq.gov/issue/medical-error-incident-investigation-and-second-victim-doing-better-feeling-worse
      July 29, 2020 - Commentary Medical error, incident investigation and the second victim: doing better but feeling worse? Citation Text: Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267-70. doi:10.1136/bmjqs-20…