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Showing results for "incident".

181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866351/psn-pdf
     July 24, 2024 - Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident … Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident … psnet.ahrq.gov/issue/seeking-systems-based-facilitators-safety-and-healthcare-resilience-thematic- review-incident … Incident reports provide valuable learning opportunities at individual, team, and organizational levels … This study used incident reports involving anticoagulant medication errors to demonstrate the effectiveness

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74264/psn-pdf
     January 19, 2022 - Characteristics of critical incident reporting systems in primary care: an international survey. … Characteristics of critical incident reporting systems in primary care: an international survey. … https://psnet.ahrq.gov/issue/characteristics-critical-incident-reporting-systems-primary-care-international … - survey Critical incident reporting systems (CIRS) are used to improve learning and patient safety … ., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46867/psn-pdf
     February 20, 2019 - Connecting perspectives on quality and safety: patient- level linkage of incident, adverse event and … Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and … https://psnet.ahrq.gov/issue/connecting-perspectives-quality-and-safety-patient-level-linkage-incident … - adverse-event-and Safety events in hospitalized patients are captured in three ways: incident reports … Among Dutch surgical patients, the three methods captured unique problems, but patients with an incident

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72856/psn-pdf
     March 17, 2021 - The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … https://psnet.ahrq.gov/issue/fusion-incident-learning-and-failure-mode-and-effects-analysis-data-driven … The authors propose a method which leverages a radiation oncology incident learning system with a simplified … https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system https://psnet.ahrq.gov/issue

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867641/psn-pdf
     February 26, 2025 - Open disclosure among general practitioners as second victim of a patient safety incident: a cross-sectional … Open disclosure among general practitioners as second victim of a patient safety incident: a cross-sectional … https://psnet.ahrq.gov/issue/open-disclosure-among-general-practitioners-second-victim-patient-safety- incident-cross … included 78 general practitioners in Belgium, found that 87% had been involved in a patient safety incident … Only half of respondents were involved in an open discourse process after the incident, but participation

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866590/psn-pdf
     August 28, 2024 - Risk controls identified in action plans following serious incident investigations in secondary care … Risk controls identified in action plans following serious incident investigations in secondary care … https://psnet.ahrq.gov/issue/risk-controls-identified-action-plans-following-serious-incident-investigations … - secondary Patient safety incident investigations offer unique opportunities to encourage continuous … hospital in the United Kingdom to assess how well the proposed patient safety actions generated from incident

187. Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes. | PSNet
     psnet.ahrq.gov/issue/benchmarking-surgical-incident-reports-using-database-and-triage-system-reduce-adverse
     June 18, 2008 - Study Benchmarking surgical incident reports using a database and a triage system … Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes … This study, like most studies of data derived from incident reports, is limited because voluntary reports … Nonetheless, the study illustrates how to use incident reporting data within an appropriate conceptual … Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes

188. 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.

189. 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

190. 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

191. 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

192. Final Progress Report: Patient Safety in Hospice Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
     January 01, 2024 - or to increase the risk of an incident. 3. … Incident characteristics: These are selected attributes of the incident itself. … , the agents and activities related to the incident, timing, place, and other basic attributes. … each patient safety incident fit within. 3. … moderate the progression of the incident toward harming the patient” (mitigating factors)?

193. 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

194. Grant Final Report: Toward an Optimal Patient Safety Information System (TOPSIS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/koss-report.pdf
     January 01, 2024 - The PSET and hospital incident report data were used to develop a hospital incident reporting ontology … code and incident report number. … Incident Report Classification. … month incident report data collection period. … Information Collected by Incident Reporting Systems.

195. 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

196. 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

197. 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

198. 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

199. 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.

200. 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.