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Showing results for "incident".

241. 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

242. 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

243. 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

244. 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

245. 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

246. 2024 Network of Patient Safety Databases Chartbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
     January 01, 2024 - Below, determinations of preventability for an Incident are examined across patient age groups. … specified: 54,446 (91.9%) reported that the Incident Likely could have been prevented (i.e., the Incident … This suggests a slight disparity in INCIDENT PREVENTABILITY between patients Under 18 and all other … preventable was the incident?” … “How preventable was the incident?”

247. 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://

248. 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

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. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34804/psn-pdf
     January 05, 2017 - Incident reporting system does not detect adverse drug events: a problem for quality improvement. … The incident reporting system does not detect adverse drug events: a problem for quality improvement … https://psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem- … report and whether differences existed among hospital personnel as to whether an incident report should … After identifying ADEs in this single-center study, only 6% had a corresponding incident report submitted

251. 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

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867226/psn-pdf
     December 04, 2024 - The nature of the response to airway management incident reports in high income countries: a scoping … The nature of the response to airway management incident reports in high income countries: a scoping … https://psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries … https://psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries-scoping-review … https://psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries-scoping-review

253. 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

254. Possible solutions for barriers in incident reporting by residents. | PSNet
     psnet.ahrq.gov/issue/possible-solutions-barriers-incident-reporting-residents
     April 14, 2011 - Study Possible solutions for barriers in incident reporting by residents. … Possible solutions for barriers in incident reporting by residents. … Possible solutions for barriers in incident reporting by residents. … impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident

255. Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis. | PSNet
     psnet.ahrq.gov/issue/patient-safety-incidents-involving-sick-children-primary-care-england-and-wales-mixed-methods
     October 12, 2016 - In this mixed methods study, researchers analyzed incident reports involving sick pediatric primary care … An accompanying editorial discusses the value of incident reports with regard to improving care for … July 3, 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

256. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. | PSNet
     psnet.ahrq.gov/issue/sources-unsafe-primary-care-older-adults-mixed-methods-analysis-patient-safety-incident
     October 12, 2016 - Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident … Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident … Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident … October 12, 2016 Harms from discharge to primary care: mixed methods analysis of incident … September 26, 2018 Nature of blame in patient safety incident reports: mixed methods

257. How to mitigate the effects of cognitive biases during patient safety incident investigations. | PSNet
     psnet.ahrq.gov/issue/how-mitigate-effects-cognitive-biases-during-patient-safety-incident-investigations
     June 29, 2022 - Commentary How to mitigate the effects of cognitive biases during patient safety incident … How to mitigate the effects of cognitive biases during patient safety incident investigations. … How to mitigate the effects of cognitive biases during patient safety incident investigations. … Rapid-cycle improvement during the COVID-19 pandemic: using safety reports to inform incident … Analysis of incident reports from a patient safety organization.

258. 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

259. 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

260. 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