-
psnet.ahrq.gov/issue/quality-gaps-identified-through-mortality-review
March 06, 2005 - Study
Quality gaps identified through mortality review. … Quality gaps identified through mortality review. … This study described the implementation of an institution-wide mortality review process, which identified … Quality gaps identified through mortality review.
-
psnet.ahrq.gov/issue/family-identified-barriers-medication-reconciliation
February 08, 2017 - Study
Family-identified barriers to medication reconciliation. … Family-identified barriers to medication reconciliation. … Family-identified barriers to medication reconciliation.
-
psnet.ahrq.gov/issue/priority-patient-safety-issues-identified-perioperative-nurses
November 11, 2015 - Study
Priority patient safety issues identified by perioperative nurses. … Priority patient safety issues identified by perioperative nurses. … Perioperative nurses identified wrong-site surgery and medication errors as the most pressing patient … Priority patient safety issues identified by perioperative nurses.
-
psnet.ahrq.gov/issue/recurrent-obstetric-management-mistakes-identified-simulation
March 08, 2017 - Audiovisual Presentation
Recurrent obstetric management mistakes identified by simulation … Recurrent Obstetric Management Mistakes Identified by Simulation. … Recurrent Obstetric Management Mistakes Identified by Simulation. … medication containers during pharmacist transitional care visits and impact on medication discrepancies identified
-
psnet.ahrq.gov/issue/outpatient-adverse-drug-events-identified-screening-electronic-health-records
June 08, 2016 - Study
Outpatient adverse drug events identified by screening electronic health records … Outpatient adverse drug events identified by screening electronic health records. … study screened electronic medical records for evidence of ADEs using several different algorithms, and identified … The highest yield screening algorithms were triggers that identified patients with abnormal lab values … Outpatient adverse drug events identified by screening electronic health records.
-
psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system
January 10, 2018 - Special or Theme Issue
Systematically Identified Failure Is the Route to a Successful
-
psnet.ahrq.gov/issue/learning-latent-safety-threats-identified-during-simulation-improve-patient-safety
November 16, 2022 - Study
Learning from latent safety threats identified during simulation to improve … Learning from latent safety threats identified during simulation to improve patient safety. … This article describes the classification of 1,318 latent safety threats identified from 232 simulations … Learning from latent safety threats identified during simulation to improve patient safety.
-
psnet.ahrq.gov/issue/contributing-factors-identified-hospital-incident-report-narratives
March 04, 2009 - Study
Contributing factors identified by hospital incident report narratives. … Contributing factors identified by hospital incident report narratives. … Contributing factors identified by hospital incident report narratives.
-
psnet.ahrq.gov/issue/analysis-pharmacist-identified-medication-related-problems-two-united-kingdom-hospitals
July 31, 2019 - Study
Analysis of pharmacist-identified medication-related problems at two United … Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective … The majority (70%) of medication errors were identified during or before the first inpatient admission … However, the study also identified that medication errors continue throughout the hospital stay, indicating … Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective
-
psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative
June 14, 2023 - Study
Prevalence of triggers and patient harm identified by Global Trigger Tool in … Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care … Of the 26 cases identified by the GTT, 16 were considered part of the patient's disease trajectory or … Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care … , 2022
Monitoring preventable adverse events and near misses: number and type identified
-
psnet.ahrq.gov/issue/identified-safety-risks-splitting-and-crushing-oral-medications
January 21, 2009 - Commentary
Identified safety risks with splitting and crushing oral medications. … Identified safety risks with splitting and crushing oral medications. … Identified safety risks with splitting and crushing oral medications.
-
psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system-advanced-electronic
August 04, 2021 - Study
Failure to recognize newly identified aortic dilations in a health care system … Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic … This study discovered that more than half of newly identified aortic dilations on computed tomography … Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic
-
psnet.ahrq.gov/issue/monitoring-preventable-adverse-events-and-near-misses-number-and-type-identified-differ
June 08, 2022 - Study
Monitoring preventable adverse events and near misses: number and type identified … Monitoring preventable adverse events and near misses: number and type identified differ depending on … Using each of the three methods, this study identified the number and types of near misses and adverse … Monitoring preventable adverse events and near misses: number and type identified differ depending on
-
psnet.ahrq.gov/issue/clinician-identified-problems-and-solutions-delayed-diagnosis-primary-care-prioritize-study
December 14, 2016 - Study
Clinician-identified problems and solutions for delayed diagnosis in primary … Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study … Participants identified 33 discrete problems associated with delays in diagnosis and suggested 27 solutions … Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study … August 1, 2012
Analysis of pharmacist-identified medication-related problems at two United
-
psnet.ahrq.gov/issue/patient-and-carer-identified-factors-which-contribute-safety-incidents-primary-care
July 22, 2015 - Study
Patient and carer identified factors which contribute to safety incidents in … Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative … The investigators identified several unique themes related to safety, including difficulties in accessing … Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative
-
psnet.ahrq.gov/issue/harm-susceptibility-model-method-prioritise-risks-identified-patient-safety-reporting-systems
February 16, 2011 - Study
The harm susceptibility model: a method to prioritise risks identified in patient … The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems … reporting data to identify work areas with safety problems and rank the severity of safety problems identified … The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems
-
psnet.ahrq.gov/issue/published-literature-handoffs-hospitals-deficiencies-identified-extensive-review
March 07, 2012 - Review
The published literature on handoffs in hospitals: deficiencies identified … The published literature on handoffs in hospitals: deficiencies identified in an extensive review. … The published literature on handoffs in hospitals: deficiencies identified in an extensive review.
-
psnet.ahrq.gov/issue/observational-study-how-patients-are-identified-medication-administrations-medical-and
June 24, 2020 - Study
An observational study of how patients are identified before medication administrations … An observational study of how patients are identified before medication administrations in medical and … An observational study of how patients are identified before medication administrations in medical and
-
psnet.ahrq.gov/issue/clinician-responses-disruptive-intraoperative-behaviour-patterns-and-norms-identified
February 01, 2017 - Clinician responses to disruptive intraoperative behaviour: patterns and norms identified … Clinician responses to disruptive intraoperative behaviour: patterns and norms identified from a multinational … Clinician responses to disruptive intraoperative behaviour: patterns and norms identified from a multinational
-
psnet.ahrq.gov/issue/analysis-near-misses-identified-anesthesia-providers-intensive-care-unit
July 12, 2017 - Study
An analysis of near misses identified by anesthesia providers in the intensive … An analysis of near misses identified by anesthesia providers in the intensive care unit. … An analysis of near misses identified by anesthesia providers in the intensive care unit.