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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - Fortunately, the ICU nurse was quite experienced and appropriately administered atropine, with recovery … paradox is (i) patients deserve the best available care; (ii) the best available care is provided by experienced … However, patients cannot and should not expect to always receive this care directly from the most experienced … The hospital policy to have a patient be accompanied by sufficiently experienced staff was met, as the … The intern apparently experienced destructive friction, i.e., he was asked to act beyond his ZPD.
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psnet.ahrq.gov/issue/identification-and-characterization-adverse-drug-events-primary-care
July 16, 2015 - electronic health records and conducted telephone interviews with patients to determine whether they experienced … Less than 10% of patients experienced an adverse drug event, which the authors conclude represents an
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psnet.ahrq.gov/issue/living-aftermath-second-victim-experience-among-certified-registered-nurse-anesthetists
April 12, 2019 - This study of certified registered nurse anesthetists (CRNA) in Michigan found 20% of respondents experienced … psychological distress and 16% experienced physical distress.
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psnet.ahrq.gov/issue/adverse-events-hospitals-national-incidence-among-medicare-beneficiaries
October 16, 2012 - landmark Harvard Medical Practice Study , this study found that 13.5% of hospitalized Medicare patients experienced … However, fewer than 2% of patients experienced either a never event or a preventable complication for
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psnet.ahrq.gov/issue/adverse-events-skilled-nursing-facilities-national-incidence-among-medicare-beneficiaries
February 15, 2017 - Approximately 22% of beneficiaries who stayed in a skilled nursing facility experienced an adverse event … More than half of those who experienced harm were readmitted to the hospital.
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psnet.ahrq.gov/issue/adverse-events-hospitals-care-study-incidence-among-medicare-beneficiaries-two-selected
January 14, 2009 - Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's
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psnet.ahrq.gov/node/35551/psn-pdf
June 08, 2010 - indicator in surgical patients, this study used a cohort of more than
44,000 to identify 200 patients who experienced … Investigators discovered that more than half of these patients experienced at least one incident or
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to … A meliorable ADE are events in which the patient experienced harm from a medication that, while not … If the incorrect dose was dispensed and administered but the patient experienced no clinical consequences … excessively large dose was administered, the overdose was detected by abnormal lab results, but the patient experienced … considered an ameliorable ADE (that is, earlier detection could have reduced the level of harm the patient experienced
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - #2
https://psnet.ahrq.gov//#5
subdural hematomas and skull fractures can be detected even by less experienced … Importance of Experienced Radiologists
When clinicians order imaging tests, the findings of abuse are … later died and 10 survived with handicap.9
Evaluating skeletal surveys of younger children requires experienced … hemorrhage and skull fracture than
ultrafast brain MRI, suspicious findings can still be missed by less experienced … If an experienced radiologist is not available overnight, institutions should establish
clear discharge
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psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system-resilience-case-covid
February 16, 2022 - The study highlighted that preexisting gaps in care experienced by those with chronic conditions or … A systematic review of workplace triggers of emotions in the healthcare environment, the emotions experienced
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psnet.ahrq.gov/node/44819/psn-pdf
June 21, 2016 - This cohort study examined treatment patterns for patients who had
experienced a nonfatal opioid overdose … patients were prescribed opioids following such
events, and within 2 years up to 17% of those patients experienced
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psnet.ahrq.gov/node/38428/psn-pdf
February 18, 2009 - Less than 1% of patients
experienced a never event, and approximately 4% experienced a condition on
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psnet.ahrq.gov/node/40037/psn-pdf
September 20, 2011 - landmark
Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced … However, fewer than 2% of patients
experienced either a never event or a preventable complication for
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psnet.ahrq.gov/issue/publics-views-medical-error-massachusetts
January 30, 2019 - This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced … About half of patients who experienced medical errors reported the incident to a clinician, hospital,
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - During the first COVID-19 surge, the hospital staff experienced a relatively high patient census, including … The innovation team, led by experienced hospitalists, attempted to meet the demand for patient care while … They trained 15 experienced hospitalists to work virtually to support the onsite clinicians. … described by the innovation team, the innovation was a work stream and staffing model that incorporated 15 experienced … Some COVID-19 patients’ families experienced solitude, powerlessness, and interruptions in the relationship
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psnet.ahrq.gov/node/45554/psn-pdf
October 19, 2016 - This Swedish study
looked at a previously unexamined aspect of safety—harm experienced by patients while … The population-based analysis found that patients experienced an
increased risk of adverse events during
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psnet.ahrq.gov/node/43254/psn-pdf
May 01, 2015 - multiple Medicare databases over a 7-year period, this study found that nearly
1 in 5 older adults experienced … Patients who experienced an adverse medical event had much higher mortality rates, though it
should
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - An adverse drug event (ADE) is
defined as harm experienced by a patient as a result of exposure to a … Ameliorable ADE are events in which the patient experienced harm from a medication that, while not
completely … If the
incorrect dose was dispensed and administered but the patient experienced no clinical consequences … excessively large dose was administered, the overdose was detected by
abnormal lab results, but the patient experienced … considered an ameliorable ADE (that is, earlier detection could have
reduced the level of harm the patient experienced
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psnet.ahrq.gov/issue/disrupting-diagnostic-reasoning-do-interruptions-instructions-and-experience-affect
February 06, 2014 - While the experienced physicians answered the questions more quickly and accurately compared to resident … : a narrative analysis of experienced physicians' stories of preventable error.
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psnet.ahrq.gov/issue/patient-harm-events-and-associated-cost-outcomes-reported-patient-safety-organization
July 18, 2017 - an electronic trigger tool, researchers in this study evaluated financial impacts among patients who experienced … Patients who experienced preventable harm had longer length of stay and higher costs compared to patients