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Showing results for "incident".

181. Unit-based incident reporting and root cause analysis: variation at three hospital unit types. | PSNet
     psnet.ahrq.gov/issue/unit-based-incident-reporting-and-root-cause-analysis-variation-three-hospital-unit-types
     April 14, 2011 - Study Unit-based incident reporting and root cause analysis: variation at three hospital … Unit-based incident reporting and root cause analysis: variation at three hospital unit types. … Incident reporting systems and root cause analyses remain the main mechanisms by which adverse events … This study sought to determine whether more localized, unit-based incident reporting systems might provide … Unit-based incident reporting and root cause analysis: variation at three hospital unit types.

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867082/psn-pdf
     November 06, 2024 - Learning in radiation oncology: 12-month experience with a new incident learning system. … month experience with a new incident learning system. … https://psnet.ahrq.gov/issue/learning-radiation-oncology-12-month-experience-new-incident-learning- … system An incident learning system (ILS) can highlight system weaknesses and promote organizational … https://psnet.ahrq.gov/issue/learning-radiation-oncology-12-month-experience-new-incident-learning-system

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50775/psn-pdf
     January 01, 2021 - Content analysis of patient safety incident reports for older adult patient transfers, handovers, and … Content analysis of patient safety incident reports for older adult patient transfers, handovers, and … https://psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers … Half of all incident reports involved interunit/department/team transfers and the majority (69%) of … Few incident reports referenced individual or organizational learning (e.g., team discussions, root

184. Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. | PSNet
     psnet.ahrq.gov/issue/feasibility-centre-based-incident-reporting-primary-healthcare-spiegel-study
     October 05, 2011 - Study Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL … Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. … This study investigates the local implementation and feasibility of an incident reporting system for … Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. … September 7, 2016 Effects of patient safety culture interventions on incident reporting

185. The impact of COVID-19 workflow changes on radiation oncology incident reporting. | PSNet
     psnet.ahrq.gov/issue/impact-covid-19-workflow-changes-radiation-oncology-incident-reporting
     June 30, 2021 - Study The impact of COVID-19 workflow changes on radiation oncology incident reporting … The impact of COVID‐19 workflow changes on radiation oncology incident reporting. … The impact of COVID‐19 workflow changes on radiation oncology incident reporting. … Resources From the Same Author(s) Impact of technological and departmental changes on incident … June 30, 2021 Evaluating incident learning systems and safety culture in two radiation

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50659/psn-pdf
     November 13, 2019 - Barriers and facilitators to incident reporting in mental healthcare settings: a qualitative study. … Barriers and facilitators to incident reporting in mental healthcare settings: a qualitative study. … https://psnet.ahrq.gov/issue/barriers-and-facilitators-incident-reporting-mental-healthcare-settings- … qualitative study of staff in mental healthcare settings and assessed the barriers and facilitators to incident … The authors identified unique challenges to incident reporting in mental health, including the incidence

187. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60872/psn-pdf
     September 02, 2020 - How incident reporting systems can stimulate social and participative learning: a mixed-methods study … How incident reporting systems can stimulate social and participative learning: a mixed-methods study … https://psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning … - mixed-methods Using qualitative and quantitative data, this study evaluated how incident reporting … The authors identified five core areas related to incident reporting: (1) changed staff attitudes and

188. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47365/psn-pdf
     January 01, 2019 - How well do incident reporting systems work on inpatient psychiatric units? … How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units? … https://psnet.ahrq.gov/issue/how-well-do-incident-reporting-systems-work-inpatient-psychiatric-units … A recent commentary discussed the inherent limitations of incident reporting systems and suggested ways … https://psnet.ahrq.gov/issue/how-well-do-incident-reporting-systems-work-inpatient-psychiatric-units

189. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866814/psn-pdf
     September 25, 2024 - Accuracy of a proprietary large language model in labeling obstetric incident reports. … Accuracy of a proprietary large language model in labeling obstetric incident reports. … https://psnet.ahrq.gov/issue/accuracy-proprietary-large-language-model-labeling-obstetric-incident-reports … Voluntary incident reporting is an important resource for identifying adverse events and near misses … https://psnet.ahrq.gov/issue/accuracy-proprietary-large-language-model-labeling-obstetric-incident-reports

190. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50753/psn-pdf
     December 18, 2019 - The contribution of staffing to medication administration errors: a text mining analysis of incident … The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incident … /psnet.ahrq.gov/issue/contribution-staffing-medication-administration-errors-text-mining-analysis- incident-report … retrospective study used descriptive statistics, manual analysis, and text mining of medication-related incident … The key importance of this article is the use of an automated system to analyze incident reports.

191. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837144/psn-pdf
     May 18, 2022 - Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. … Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. … https://psnet.ahrq.gov/issue/differences-hospitals-workplace-violence-incident-reporting-practices-mixed … This article describes data collected during the first three years of a new statewide incident reporting … system, California’s Workplace Violent Incident Reporting System (WVIRS) for Hospitals.

192. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73923/psn-pdf
     October 06, 2021 - Suicide risk, changing jobs, or leaving the nursing profession in the aftermath of a patient safety incident … Suicide risk, changing jobs, or leaving the nursing profession in the aftermath of a patient safety incident … psnet.ahrq.gov/issue/suicide-risk-changing-jobs-or-leaving-nursing-profession-aftermath-patient- safety-incident … Clinicians who are involved in a patient safety incident often experience significant emotional consequences … This study found that nurses involved in an patient safety incident resulting in patient death were

193. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/858171/psn-pdf
     December 13, 2023 - Uncovering the risks of anticancer therapy through incident report analysis using a newly developed … medical oncology incident taxonomy. … Uncovering the risks of anticancer therapy through incident report analysis using a newly developed … medical oncology incident taxonomy. … https://psnet.ahrq.gov/issue/uncovering-risks-anticancer-therapy-through-incident-report-analysis-using

194. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852444/psn-pdf
     August 16, 2023 - Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic … Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic … https://psnet.ahrq.gov/issue/comparing-rates-adverse-events-detected-incident-reporting-and-global- … difference in adverse events detected using the Global Trigger Tool compared to those detected via incident … than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident

195. Healthcare professionals' encounters with ethnic minority patients: the critical incident approach. | PSNet
     psnet.ahrq.gov/issue/healthcare-professionals-encounters-ethnic-minority-patients-critical-incident-approach
     July 29, 2020 - Healthcare professionals' encounters with ethnic minority patients: the critical incident … Healthcare professionals’ encounters with ethnic minority patients: the critical incident approach. … Healthcare professionals’ encounters with ethnic minority patients: the critical incident approach. … August 25, 2021 Evaluation of older persons' medications: a critical incident technique … October 6, 2021 Long-term care nurses' experiences with patient safety incident management

196. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50795/psn-pdf
     January 15, 2020 - Diagnostic error in the emergency department: learning from national patient safety incident report … Diagnostic error in the emergency department: learning from national patient safety incident report … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety- incident-report … This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency … https://psnet.ahrq.gov/issue/problem-incident-reporting https://psnet.ahrq.gov/primer/diagnostic-errors

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44532/psn-pdf
     December 21, 2018 - The problem with incident reporting. December 21, 2018 Macrae C. … The problem with incident reporting. … https://psnet.ahrq.gov/issue/problem-incident-reporting This commentary discusses weaknesses in health … care incident reporting systems that limit their ability to contribute to improvements, including overreporting … https://psnet.ahrq.gov/issue/problem-incident-reporting https://psnet.ahrq.gov/primer/reporting-patient-safety-events

198. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44744/psn-pdf
     June 21, 2016 - Can patient safety incident reports be used to compare hospital safety? … Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? … https://psnet.ahrq.gov/issue/can-patient-safety-incident-reports-be-used-compare-hospital-safety-results … Incident reports provide one lens into patient safety, despite concerns about under-reporting. … Numerous incident reports may indicate either a high number of errors or a robust safety culture that

199. Rates of safety incident reporting in MRI in a large academic medical center. | PSNet
     psnet.ahrq.gov/issue/rates-safety-incident-reporting-mri-large-academic-medical-center
     May 03, 2017 - Study Rates of safety incident reporting in MRI in a large academic medical center … Rates of safety incident reporting in MRI in a large academic medical center. … This analysis of incident reports related to magnetic resonance imaging found that, similar to other … settings , incident reports are infrequent, and most do not result in patient harm. … Rates of safety incident reporting in MRI in a large academic medical center.

200. Worries and concerns experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident study. | PSNet
     psnet.ahrq.gov/issue/worries-and-concerns-experienced-nurse-specialists-during-inter-hospital-transports
     September 19, 2016 - experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident … experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident … This Swedish study used critical incident debriefing techniques to explore factors leading to potential … experienced by nurse specialists during inter-hospital transports of critically ill patients: a critical incident … January 30, 2019 How well do incident reporting systems work on inpatient psychiatric