Results

Total Results: 2,541 records

Showing results for "incident".

2261. Opinions of nurses and physicians on a patient, family and visitor activated rapid response system in use across two hospital settings. | PSNet
      psnet.ahrq.gov/issue/opinions-nurses-and-physicians-patient-family-and-visitor-activated-rapid-response-system-use
      February 14, 2024 - Study Opinions of nurses and physicians on a patient, family and visitor activated rapid response system in use across two hospital settings. Citation Text: King L, Minyaev S, Grantham H, et al. Opinions of nurses and physicians on a patient, family and visitor activated rapid response s…

2262. A multi-facetted patient safety resource--a qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team. | PSNet
      psnet.ahrq.gov/issue/multi-facetted-patient-safety-resource-qualitative-interview-study-hospital-managers
      September 20, 2023 - Study A multi-facetted patient safety resource--a qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team. Citation Text: Axelsen MS, Baumgarten M, Egholm CL, et al. A multi‐facetted patient safety resource—a qualitative interview study on hospit…

2263. Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis. | PSNet
      psnet.ahrq.gov/issue/outcomes-and-patient-safety-overlapping-vs-nonoverlapping-total-joint-arthroplasty-systematic
      February 02, 2022 - Review Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis. Citation Text: Malahias M-A, Antoniadou T, Jang SJ, et al. Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a syste…

2264. Exploring safety culture within inpatient mental health units: the results from participant observation across three mental health services. | PSNet
      psnet.ahrq.gov/issue/exploring-safety-culture-within-inpatient-mental-health-units-results-participant-observation
      September 23, 2020 - Study Exploring safety culture within inpatient mental health units: the results from participant observation across three mental health services. Citation Text: Molloy L, Wilson V, O'Connor MF, et al. Exploring safety culture within inpatient mental health units: the results from partic…

2265. Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study. | PSNet
      psnet.ahrq.gov/issue/compliance-and-barriers-implementing-surgical-safety-checklist-mixed-methods-study
      October 06, 2021 - Study Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study. Citation Text: Aydin Akbuga G, Sürme Y, Esenkaya D. Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study. AORN J. 2023;117(2):e1-e10. doi:…

2266. Interventions promoting employee "speaking-up" within healthcare workplaces: a systematic narrative review of the international literature. | PSNet
      psnet.ahrq.gov/issue/interventions-promoting-employee-speaking-within-healthcare-workplaces-systematic-narrative
      May 19, 2021 - Review Classic Interventions promoting employee "speaking-up" within healthcare workplaces: a systematic narrative review of the international literature. Citation Text: Jones A, Blake J, Adams M, et al. Interventions promoting employee “speaking-up” within heal…

2267. Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. | PSNet
      psnet.ahrq.gov/issue/association-between-workarounds-and-medication-administration-errors-bar-code-assisted
      August 26, 2020 - Study Classic Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. Citation Text: van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication adm…

2268. Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services. | PSNet
      psnet.ahrq.gov/issue/association-pediatric-resident-physician-depression-and-burnout-harmful-medical-errors
      April 24, 2018 - Study Emerging Classic Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services. Citation Text: Brunsberg KA, Landrigan CP, Garcia BM, et al. Association of Pediatric Resident Physician Depression and B…

2269. Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. | PSNet
      psnet.ahrq.gov/issue/filling-gap-safety-metrics-development-patient-centred-framework-identify-and-categorise
      February 15, 2023 - Study Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. Citation Text: Bell SK, Bourgeois FC, DesRoches CM, et al. Filling a gap in safety metrics: devel…

2270. Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool. | PSNet
      psnet.ahrq.gov/issue/performance-global-assessment-pediatric-patient-safety-gapps-tool
      August 14, 2018 - Study Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool. Citation Text: Landrigan CP, Stockwell DC, Toomey SL, et al. Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool. Pediatrics. 2016;137(6). doi:10.1542/peds.2015-4076. Copy Cit…

2271. In Conversation With… Timothy B. McDonald, MD, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
      February 26, 2025 - March 9, 2022 Communication and Resolution After an Adverse Health Care Incident.

2272. Mismanagement of Delirium | PSNet
      psnet.ahrq.gov/web-mm/mismanagement-delirium
      February 13, 2014 - Since the precipitating incident, the patient has lost 40 lbs.

2273. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49801/psn-pdf
      August 01, 2017 - They do not capture the nuances of care coordination or lack thereof immediately prior to or after an incident

2274. The Perils of Cross Coverage | PSNet
      psnet.ahrq.gov/web-mm/perils-cross-coverage
      September 22, 2010 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

2275. Triple Handoff | PSNet
      psnet.ahrq.gov/web-mm/triple-handoff
      March 01, 2004 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

2276. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy | PSNet
      psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
      July 01, 2008 - November 21, 2016 What prevents incident disclosure, and what can be done to promote

2277. Value and Patient Safety | PSNet
      psnet.ahrq.gov/curated-library/value-and-patient-safety
      October 30, 2019 - analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident

2278. Procedural Mishap: Learning Curve? | PSNet
      psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
      April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

2279. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room | PSNet
      psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
      February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room Citation Text: Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…

2280. Spotlight
      psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
      January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…