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Showing results for "incident".

221. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73865/psn-pdf
     September 22, 2021 - Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: an … Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: an … psnet.ahrq.gov/issue/second-victims-among-baccalaureate-nursing-students-aftermath-patient- safety-incident … nursing students in Belgium found that about one in three students were involved in a patient safety incident … //psnet.ahrq.gov/issue/second-victims-among-baccalaureate-nursing-students-aftermath-patient-safety-incident

222. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841768/psn-pdf
     December 21, 2022 - implementation-online-reporting-system-identify-unprofessional-behaviors-and- mistreatment The effectiveness of incident … This cohort study describes the characteristics of incident reports submitted by trainees in a large … From October 2019 through December 2021, trainees submitted nearly 200 incident reports, primarily describing … Findings suggest that awareness and support for the online incident reporting system among trainees … https://psnet.ahrq.gov/issue/improving-incident-reporting-among-physician-trainees

223. Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping review. | PSNet
     psnet.ahrq.gov/issue/exploring-black-box-recommendation-generation-local-health-care-incident-investigations
     November 16, 2016 - Review Exploring the "Black Box" of recommendation generation in local health care incident … Exploring the "Black Box" of recommendation generation in local health care incident investigations: … Organizational incident reporting allows for investigation of contributing factors and formation of … Exploring the "Black Box" of recommendation generation in local health care incident investigations: … Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident

224. Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports. | PSNet
     psnet.ahrq.gov/issue/health-and-social-care-associated-harm-amongst-vulnerable-children-primary-care-mixed-methods
     October 12, 2016 - Using a national database of patient safety incident reports in the United Kingdom, this study characterized … Over 1,100 incident reports were identified; nearly half resulted in some degree of harm but most (39% … October 12, 2016 Harms from discharge to primary care: mixed methods analysis of incident … Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident … September 26, 2018 Nature of blame in patient safety incident reports: mixed methods

225. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/856640/psn-pdf
     November 29, 2023 - Research from webAIRS incident reporting system. … https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system Centralized de-identified reports … https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system https://psnet.ahrq.gov/primer … /reporting-patient-safety-events https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system … https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system https://psnet.ahrq.gov/web-mm

226. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. | PSNet
     psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report
     January 22, 2014 - Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … July 18, 2016 Harms from discharge to primary care: mixed methods analysis of incident … report analysis using a newly developed medical oncology incident taxonomy.

227. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60618/psn-pdf
     June 24, 2020 - methods of detecting medication errors: a secondary analysis of medication administration errors using incident … methods of detecting medication errors: a secondary analysis of medication administration errors using incident … differences-between-methods-detecting-medication-errors-secondary-analysis- medication This study compared medication errors detected using incident … Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause … For example, incident reports most commonly identified wrong dose and wrong time errors.

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853429/psn-pdf
     September 13, 2023 - Multifaceted intervention to improve patient safety incident reporting in intensive care units. … Multifaceted intervention to improve patient safety incident reporting in intensive care units. … https://psnet.ahrq.gov/issue/multifaceted-intervention-improve-patient-safety-incident-reporting-intensive … https://psnet.ahrq.gov/issue/multifaceted-intervention-improve-patient-safety-incident-reporting-intensive-care-units … https://psnet.ahrq.gov/issue/multifaceted-intervention-improve-patient-safety-incident-reporting-intensive-care-units

229. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50750/psn-pdf
     January 01, 2020 - Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting … Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting … ://psnet.ahrq.gov/issue/patterns-medication-incidents-10-yr-experience-cross-national-anaesthesia- incident-reporting … This article presents a descriptive analysis of the MRE reported to the Spanish Anaesthesia Incident … https://psnet.ahrq.gov/issue/patterns-medication-incidents-10-yr-experience-cross-national-anaesthesia-incident-reporting

230. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73246/psn-pdf
     May 12, 2021 - Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health … Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health … https://psnet.ahrq.gov/issue/self-reported-learning-srl-voluntary-incident-reporting-system-experience … https://psnet.ahrq.gov/issue/self-reported-learning-srl-voluntary-incident-reporting-system-experience-within-large-health … https://psnet.ahrq.gov/issue/self-reported-learning-srl-voluntary-incident-reporting-system-experience-within-large-health

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846161/psn-pdf
     March 15, 2023 - Ten years of online incident reporting and learning using CPiRLS: implications for improved patient … Ten years of online incident reporting and learning using CPiRLS: implications for improved patient … https://psnet.ahrq.gov/issue/ten-years-online-incident-reporting-and-learning-using-cpirls-implications … - improved-patient Patient safety incident reporting is an important tool for characterizing events … https://psnet.ahrq.gov/issue/ten-years-online-incident-reporting-and-learning-using-cpirls-implications-improved-patient

232. Cultural and associated enablers of, and barriers to, adverse incident reporting. | PSNet
     psnet.ahrq.gov/issue/cultural-and-associated-enablers-and-barriers-adverse-incident-reporting
     March 23, 2011 - Study Cultural and associated enablers of, and barriers to, adverse incident reporting … Cultural and associated enablers of, and barriers to, adverse incident reporting. … Cultural and associated enablers of, and barriers to, adverse incident reporting. … June 14, 2011 Attitudes toward the large-scale implementation of an incident reporting … June 29, 2011 Implementation of a patient safety incident management system as viewed

233. Strategies and Approaches for Investigating Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
     March 15, 2025 - Tools covered in this primer include incident reporting systems , Root Cause Analysis (RCA) , and … Incident Reporting Systems Incident reporting systems are widely used by health care organizations to … Incident reporting systems provide insights into patient harms at the organizational level and can … To be maximally effective, incident reporting systems should be coupled with supportive institutional … Incident reporting systems are a form of passive surveillance and therefore have limitations in their

234. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837857/psn-pdf
     August 17, 2022 - Patient and family involvement in serious incident investigations from the perspectives of key stakeholders … Patient and family involvement in serious incident investigations from the perspectives of key stakeholders … https://psnet.ahrq.gov/issue/patient-and-family-involvement-serious-incident-investigations-perspectives … qualitative evidence review concluded that patients and families value involvement in patient safety incident … https://psnet.ahrq.gov/issue/patient-and-family-involvement-serious-incident-investigations-perspectives-key-stakeholders

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853428/psn-pdf
     September 13, 2023 - Intensive care unit critical incident analysis as an objective tool to select content for a simulation … Intensive care unit critical incident analysis as an objective tool to select content for a simulation … https://psnet.ahrq.gov/issue/intensive-care-unit-critical-incident-analysis-objective-tool-select-content … This process of integrating critical incident data with trainee self-assessment can be generalized to … https://psnet.ahrq.gov/issue/intensive-care-unit-critical-incident-analysis-objective-tool-select-content-simulation

236. A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. | PSNet
     psnet.ahrq.gov/issue/mixed-methods-analysis-patient-safety-incidents-involving-opioid-substitution-treatment
     August 25, 2021 - Using national data from England and Wales, this study analyzed 2,284 patient safety incident reports … August 25, 2021 Characterising the nature of primary care patient safety incident reports … December 16, 2020 Harms from discharge to primary care: mixed methods analysis of incident … GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident … September 26, 2018 Nature of blame in patient safety incident reports: mixed methods

237. Getting the whole story: integrating patient complaints and staff reports of unsafe care. | PSNet
     psnet.ahrq.gov/issue/getting-whole-story-integrating-patient-complaints-and-staff-reports-unsafe-care
     January 12, 2022 - This retrospective study linked patient complaint data with staff incident reports to better understand … reported incidents with linked patient complaints frequently described greater harm from the safety incident … July 28, 2021 Integrating incident data from five reporting systems to assess patient … March 21, 2017 A comprehensive overview of medical error in hospitals using incident-reporting … found in patient records reported by patients and healthcare professionals via complaints, claims and incident

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865874/psn-pdf
     May 15, 2024 - Perceptions of U.S. and U.K. incident reporting systems: a scoping review. … Perceptions of U.S. and U.K. incident reporting systems: a scoping review. … https://psnet.ahrq.gov/issue/perceptions-us-and-uk-incident-reporting-systems-scoping-review Incident … https://psnet.ahrq.gov/issue/perceptions-us-and-uk-incident-reporting-systems-scoping-review https://

239. Long-term care nurses' experiences with patient safety incident management: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/long-term-care-nurses-experiences-patient-safety-incident-management-qualitative-study
     March 24, 2021 - Study Long-term care nurses' experiences with patient safety incident management: … Long-term care nurses' experiences with patient safety incident management: a qualitative study. … Long-term care nurses' experiences with patient safety incident management: a qualitative study. … Implementing the clinical occurrence reporting and learning system: a double-loop learning incident … 19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48152/psn-pdf
     July 17, 2019 - Safety incident reports associated with blood transfusions. … Safety incident reports associated with blood transfusions. … https://psnet.ahrq.gov/issue/safety-incident-reports-associated-blood-transfusions This analysis of … transfusion-related safety incident reports found that such events were more commonly reported for pediatric … https://psnet.ahrq.gov/issue/safety-incident-reports-associated-blood-transfusions https://psnet.ahrq.gov