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Showing results for "incident".

341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44003/psn-pdf
     June 17, 2015 - Effects of patient safety culture interventions on incident reporting in general practice: a cluster … Effects of patient safety culture interventions on incident reporting in general practice: a cluster … https://psnet.ahrq.gov/issue/effects-patient-safety-culture-interventions-incident-reporting-general-practice … team-based workshop and facilitated discussion around safety issues resulted in an increase in voluntary incident … https://psnet.ahrq.gov/issue/effects-patient-safety-culture-interventions-incident-reporting-general-practice-cluster

342. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837982/psn-pdf
     August 31, 2022 - Patient Safety Incident Response Framework. … https://psnet.ahrq.gov/issue/patient-safety-incident-response-framework Effective response to medical … error requires a comprehensive systemic and process-focused incident examination approach to ensure … https://psnet.ahrq.gov/issue/patient-safety-incident-response-framework https://psnet.ahrq.gov/primer

343. Patient Safety Concerns Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2022.xlsx
     January 01, 2022 - Report Type by Event Type Event Type Report Type Percentage Frequency Total Blood or Blood Product Incident … 100.0% 237,310 2,228,834 Medication or Other Substance Incident 67.0% 309,288 2,228,834 Medication … 124,078 2,228,834 Medication or Other Substance Unsafe Condition 6.1% 28,270 2,228,834 Perinatal Incident … 100.0% 30,206 2,228,834 Pressure Ulcer Incident 100.0% 81,102 2,228,834 Surgery or Anesthesia Incident … 78.8% 100,596 2,228,834 Surgery or Anesthesia Near Miss 21.2% 27,024 2,228,834 Other Incident 68.6%

344. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43501/psn-pdf
     September 10, 2014 - Emergency department patient safety incident characterization: an observational analysis of the findings … Emergency department patient safety incident characterization: an observational analysis of the findings … https://psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational … characterize patient safety incidents in a tertiary care emergency department, researchers investigated incident … https://psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational-analysis-findings

345. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44858/psn-pdf
     February 10, 2016 - Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting … Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting … //psnet.ahrq.gov/issue/situation-awareness-errors-anesthesia-and-critical-care-200-cases-critical- incident-reporting … This retrospective review of anesthesia and critical care cases in the German incident reporting system … https://psnet.ahrq.gov/issue/situation-awareness-errors-anesthesia-and-critical-care-200-cases-critical-incident-reporting

346. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46328/psn-pdf
     August 09, 2017 - Critical incident stress debriefing after adverse patient safety events. … Critical incident stress debriefing after adverse patient safety events. … https://psnet.ahrq.gov/issue/critical-incident-stress-debriefing-after-adverse-patient-safety-events … https://psnet.ahrq.gov/issue/critical-incident-stress-debriefing-after-adverse-patient-safety-events … https://psnet.ahrq.gov/issue/psychological-impact-and-recovery-after-involvement-patient-safety-incident-repeated-measures

347. Practising open disclosure: clinical incident communication and systems improvement. | PSNet
     psnet.ahrq.gov/issue/practising-open-disclosure-clinical-incident-communication-and-systems-improvement
     November 23, 2016 - Commentary Practising open disclosure: clinical incident communication and systems … Practising Open Disclosure: clinical incident communication and systems improvement. … Practising Open Disclosure: clinical incident communication and systems improvement. … September 6, 2017 Narrativizing errors of care: critical incident reporting in clinical … Patients' and family members' views on how clinicians enact and how they should enact incident

348. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836812/psn-pdf
     March 30, 2022 - Tools covered in this primer include incident reporting systems, Root Cause Analysis (RCA), and Failure … Incident Reporting Systems Incident reporting systems are widely used by health care organizations to … 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 … Barriers to incident reporting include an organizational culture of blame, health care staff's fear

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45562/psn-pdf
     October 12, 2016 - Characterising the nature of primary care patient safety incident reports in the England and Wales National … Characterising The Nature Of Primary Care Patient Safety Incident Reports In The England And Wales National … https://psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england … - and-wales-national Management and analysis of incident reporting data must be enhanced in order to … were able to categorize the types of incidents and prioritize system improvements needed to optimize incident

350. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61037/psn-pdf
     January 01, 2021 - Analysis of incident reports from a patient safety organization. … Analysis of incident reports from a patient safety organization. … https://psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports … https://psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports-patient-safety … https://psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports-patient-safety

351. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48176/psn-pdf
     July 31, 2019 - Duration of second victim symptoms in the aftermath of a patient safety incident and association with … Duration of second victim symptoms in the aftermath of a patient safety incident and association with … https://psnet.ahrq.gov/issue/duration-second-victim-symptoms-aftermath-patient-safety-incident-and- … https://psnet.ahrq.gov/issue/duration-second-victim-symptoms-aftermath-patient-safety-incident-and-association-level … https://psnet.ahrq.gov/issue/duration-second-victim-symptoms-aftermath-patient-safety-incident-and-association-level

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47921/psn-pdf
     June 18, 2019 - Using incident reports to assess communication failures and patient outcomes. … Using Incident Reports to Assess Communication Failures and Patient Outcomes. … https://psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes … Investigators examined incident reports at an academic medical center to characterize how communication … https://psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes

353. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33717/psn-pdf
     September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please September 1, 2011 Nuckols … Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. … Physicians file only 1%–3% of incident reports.(10,12) Thus, incident reporting is most useful for improving … Clinical incident reporting. In: Vincent C, ed. … Contributing factors identified by hospital incident report narratives.

354. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43528/psn-pdf
     October 01, 2014 - Critical incident stress management (CISM) in complex systems: cultural adaptation and safety impacts … Critical Incident Stress Management (CISM) in complex systems: cultural adaptation and safety impacts … https://psnet.ahrq.gov/issue/critical-incident-stress-management-cism-complex-systems-cultural- adaptation-and-safety … Critical incident stress management (CISM) is a peer support program that has previously been utilized … https://psnet.ahrq.gov/issue/critical-incident-stress-management-cism-complex-systems-cultural-adaptation-and-safety

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44902/psn-pdf
     February 24, 2016 - Barriers to incident-reporting behavior among nursing staff: a study based on the theory of planned … Barriers to incident-reporting behavior among nursing staff: A study based on the theory of planned … https://psnet.ahrq.gov/issue/barriers-incident-reporting-behavior-among-nursing-staff-study-based-theory … - planned-behavior Incident reporting systems are an important method for identifying system failures … https://psnet.ahrq.gov/issue/barriers-incident-reporting-behavior-among-nursing-staff-study-based-theory-planned-behavior

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42425/psn-pdf
     August 13, 2013 - The Patient-Reported Incident in Hospital Instrument (PRIH-I): assessments of data quality, test–retest … The Patient-Reported Incident in Hospital Instrument (PRIH-I): assessments of data quality, test-retest … https://psnet.ahrq.gov/issue/patient-reported-incident-hospital-instrument-prih-i-assessments-data-quality … - test-retest The Patient-Reported Incident in Hospital Instrument, which consists of 13 questions … https://psnet.ahrq.gov/issue/patient-reported-incident-hospital-instrument-prih-i-assessments-data-quality-test-retest

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44418/psn-pdf
     September 23, 2015 - Learning from patient safety incidents in incident review meetings: organisational factors and indicators … Learning from patient safety incidents in incident review meetings: Organisational factors and indicators … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-incident-review-meetings-organisational … - factors-and This observational study of incident report review meetings found that high workload, … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-incident-review-meetings-organisational-factors-and

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39479/psn-pdf
     January 20, 2011 - A comparative analysis of incident reporting lag times in academic medical centres in Japan and the … A comparative analysis of incident reporting lag times in academic medical centres in Japan and the … https://psnet.ahrq.gov/issue/comparative-analysis-incident-reporting-lag-times-academic-medical-centres … - japan-and-usa This study compared incident reporting practices at two hospitals and noted significantly … https://psnet.ahrq.gov/issue/comparative-analysis-incident-reporting-lag-times-academic-medical-centres-japan-and-usa

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34914/psn-pdf
     February 27, 2009 - Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring … Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring … https://psnet.ahrq.gov/issue/drug-error-anaesthetic-practice-review-896-reports-australian-incident- … study provides a detailed analysis of incidents due to medication errors collected from the Australian Incident … https://psnet.ahrq.gov/issue/drug-error-anaesthetic-practice-review-896-reports-australian-incident-monitoring-study

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46209/psn-pdf
     January 01, 2020 - The impact of incident disclosure behaviors on medical malpractice claims. … The Impact of Incident Disclosure Behaviors on Medical Malpractice Claims. … https://psnet.ahrq.gov/issue/impact-incident-disclosure-behaviors-medical-malpractice-claims The effect … https://psnet.ahrq.gov/issue/impact-incident-disclosure-behaviors-medical-malpractice-claims https://