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Showing results for "incident".

241. 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.

242. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46391/psn-pdf
     February 08, 2018 - Nature of blame in patient safety incident reports: mixed methods analysis of a national database. … Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. … https://psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national … - database Poor safety culture has been identified as a barrier to incident reporting. … Researchers analyzed a sample of family practice patient safety incident reports from the England and

243. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44987/psn-pdf
     February 01, 2017 - International recommendations for national patient safety incident reporting systems: an expert Delphi … International recommendations for national patient safety incident reporting systems: an expert Delphi … https://psnet.ahrq.gov/issue/international-recommendations-national-patient-safety-incident-reporting … - systems-expert Although incident reporting systems remain central to most patient safety programs … Consistent with prior research, experts agreed that incident reporting systems should not be used to

244. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47076/psn-pdf
     August 15, 2018 - Incident learning in radiation oncology: a review. August 15, 2018 Ford E, Evans SB. … Incident learning in radiation oncology: A review. Med Phys. 2018;45(5):e100-e119. … https://psnet.ahrq.gov/issue/incident-learning-radiation-oncology-review Learning from adverse events … https://psnet.ahrq.gov/issue/incident-learning-radiation-oncology-review https://psnet.ahrq.gov/issue … /radiation-oncology-incident-learning-system

245. Toward learning from patient safety reporting systems. | PSNet
     psnet.ahrq.gov/issue/toward-learning-patient-safety-reporting-systems
     January 02, 2017 - This study reports the initial findings from a voluntary, Web-based patient safety incident reporting … The authors note that the science of incident reporting systems is still in its infancy and recommend … that future research should study how to use incident reporting data to improve patient safety. … June 16, 2011 Using incident reporting to improve patient safety: a conceptual model. … : description of 4846 incident reports.

246. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864857/psn-pdf
     March 20, 2024 - Safety on the ground: using critical incident technique to explore the factors influencing medical registrars … Safety on the ground: using critical incident technique to explore the factors influencing medical registrars … https://psnet.ahrq.gov/issue/safety-ground-using-critical-incident-technique-explore-factors-influencing … https://psnet.ahrq.gov/issue/safety-ground-using-critical-incident-technique-explore-factors-influencing-medical … https://psnet.ahrq.gov/issue/safety-ground-using-critical-incident-technique-explore-factors-influencing-medical

247. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37612/psn-pdf
     February 15, 2011 - Can we use incident reports to detect hospital adverse events? … https://psnet.ahrq.gov/issue/can-we-use-incident-reports-detect-hospital-adverse-events Incident reporting … As shown in prior research, incident reports identified only a small proportion of adverse events. … A framework for analyzing and responding to incident reports was presented in an earlier study. … https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model

248. Critical incident stress debriefing after adverse patient safety events. | PSNet
     psnet.ahrq.gov/issue/critical-incident-stress-debriefing-after-adverse-patient-safety-events
     April 03, 2019 - Review Critical incident stress debriefing after adverse patient safety events. … Critical incident stress debriefing after adverse patient safety events. … Critical incident stress debriefing after adverse patient safety events.

249. 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

250. Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization. | PSNet
     psnet.ahrq.gov/issue/self-reported-learning-srl-voluntary-incident-reporting-system-experience-within-large-health
     October 26, 2022 - Study Self-Reported Learning (SRL), a voluntary incident reporting system experience … 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 … Analysis of incident reports from a patient safety organization. … February 12, 2020 Novel telephone-based interactive voice response system for incident

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36962/psn-pdf
     June 15, 2011 - Rates and types of events reported to established incident reporting systems in two US hospitals. … Rates and types of events reported to established incident reporting systems in two US hospitals. … https://psnet.ahrq.gov/issue/rates-and-types-events-reported-established-incident-reporting-systems-two … - us-hospitals Despite mandates for US hospitals to maintain incident reporting systems, little is … https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38454/psn-pdf
     January 02, 2017 - Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. … Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. … Incident reporting (IR) systems serve as an important mechanism to understand, analyze, and potentially … This study categorized more than 2200 incident reports into whether they described aberrant care processes … https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model

253. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36266/psn-pdf
     October 21, 2010 - Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical? … Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical? … https://psnet.ahrq.gov/issue/scrutinizing-incident-reporting-anaesthesia-why-incident-perceived-critical … https://psnet.ahrq.gov/issue/scrutinizing-incident-reporting-anaesthesia-why-incident-perceived-critical

254. 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

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851196/psn-pdf
     July 05, 2023 - Patient falls while under supervision: trends from incident reporting. July 5, 2023 Roberts M. … Patient falls while under supervision: trends from incident reporting. … https://psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-reporting Preventing … This study used one health system’s incident reporting tool in the United Kingdom to ascertain the incidence … https://psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-reporting https://

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38366/psn-pdf
     January 28, 2009 - Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes … Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes … https://psnet.ahrq.gov/issue/benchmarking-surgical-incident-reports-using-database-and-triage-system- … Nonetheless, the study illustrates how to use incident reporting data within an appropriate conceptual … https://psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model

257. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38693/psn-pdf
     June 15, 2011 - Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident … Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident … https://psnet.ahrq.gov/issue/specialty-based-voluntary-incident-reporting-neonatal-intensive-care- description … -4846 Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent … https://psnet.ahrq.gov/issue/specialty-based-voluntary-incident-reporting-neonatal-intensive-care-description

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73083/psn-pdf
     March 31, 2021 - Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after … Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after … https://psnet.ahrq.gov/issue/suicide-incident-severe-patient-harm-retrospective-cohort-study-investigations … https://psnet.ahrq.gov/issue/suicide-incident-severe-patient-harm-retrospective-cohort-study-investigations-after-suicide … https://psnet.ahrq.gov/issue/suicide-incident-severe-patient-harm-retrospective-cohort-study-investigations-after-suicide

259. 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.

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41646/psn-pdf
     September 05, 2012 - Interventions to increase clinical incident reporting in health care. … Interventions to increase clinical incident reporting in health care. … https://psnet.ahrq.gov/issue/interventions-increase-clinical-incident-reporting-health-care This systematic … review examined the effectiveness of interventions to increase incident reporting by clinicians. … Although incident reporting systems are universally used, they have been shown to capture only a small