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Showing results for "incident".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74169/psn-pdf
     December 08, 2021 - Blame is known to limit discussions of near-misses and failures, which negatively impacts learning and incident … This article describes work to examine blameful context present in anesthesiology incident documentation … https://psnet.ahrq.gov/issue/learn-not-blame https://psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national-database

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39790/psn-pdf
     March 21, 2017 - Integrating incident data from five reporting systems to assess patient safety: making sense of the … Integrating incident data from five reporting systems to assess patient safety: making sense of the … https://psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making … https://psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making-sense-elephant … https://psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making-sense-elephant

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40675/psn-pdf
     November 28, 2016 - Patients' and family members' views on how clinicians enact and how they should enact incident disclosure … Patients' and family members' views on how clinicians enact and how they should enact incident disclosure … psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they- should-enact-incident … psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they-should-enact-incident … psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they-should-enact-incident

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35876/psn-pdf
     June 18, 2013 - External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th … https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham … https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham … -4th-january-2001 https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45560/psn-pdf
     October 19, 2016 - Learning from excellence in healthcare: a new approach to incident reporting. … Learning from excellence in healthcare: a new approach to incident reporting. … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting Learning … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting https://psnet.ahrq.gov

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44967/psn-pdf
     March 16, 2016 - Wrong site surgery: a critical incident analysis of a near miss. March 16, 2016 Tichanow S. … Wrong site surgery: A critical incident analysis of a near miss. … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss Despite efforts … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss https://psnet.ahrq.gov

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44736/psn-pdf
     December 16, 2015 - Harms from discharge to primary care: mixed methods analysis of incident reports. … Harms from discharge to primary care: mixed methods analysis of incident reports. … https://psnet.ahrq.gov/issue/harms-discharge-primary-care-mixed-methods-analysis-incident-reports Adverse … https://psnet.ahrq.gov/issue/harms-discharge-primary-care-mixed-methods-analysis-incident-reports https

468. Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis. | PSNet
     psnet.ahrq.gov/issue/prescribers-perspectives-including-reason-use-information-prescriptions-and-medication-labels
     July 14, 2021 - workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident … December 8, 2021 Evaluation of older persons' medications: a critical incident technique … The nature, severity and causes of medication incidents from an Australian community pharmacy incident … July 28, 2021 Medication incident recovery and prevention utilising an Australian community … pharmacy incident reporting system: the QUMwatch study.

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836853/psn-pdf
     April 06, 2022 - https://psnet.ahrq.gov/issue/use-e-triggers-identify-diagnostic-errors-paediatric-ed Trigger tools and incident … study compared the performance of an electronic trigger tool plus manual screening versus existing incident … the trigger tool and substantiated by manual review, less than 10% were identified through existing incident

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47879/psn-pdf
     June 05, 2019 - in the health care setting has been well described and is one of the challenges in using data from incident … attitudes-nursing-students-and-clinical-instructors-towards-reporting-irregular-incidents https://psnet.ahrq.gov/issue/problem-incident-reporting … https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm https

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43960/psn-pdf
     April 01, 2015 - Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident … Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident … understanding-causes-intravenous-medication-administration-errors-hospitals- qualitative The critical incident … understanding-causes-intravenous-medication-administration-errors-hospitals-qualitative https://psnet.ahrq.gov/issue/critical-incident-technique

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61024/psn-pdf
     October 14, 2020 - on long-term care for people with intellectual disability: an interrupted time series analysis of incident … term care for people with intellectual disability: an interrupted time series analysis of incident reports … This study compared incident reporting at one Dutch long-term care facility for people with intellectual

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74059/psn-pdf
     January 01, 2022 - calculation errors and other numeracy mishaps in hospitals: analysis of the nature and enablers of incident … calculation errors and other numeracy mishaps in hospitals: analysis of the nature and enablers of incident … This retrospective study found that the majority of dose calculation errors reported to the Norwegian Incident

474. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
     March 01, 2007 - Checking for biases in incident reporting. In: Phimister JR, Bier VM, Kunreuther HC. … “The incident database will help identify improvement opportunities.” … Strategies to Improve Incident Reporting Promote and sustain a culture of learning from mistakes Make … factors, not to just create incident counts Share the learning derived from incident analyses with … reporting system More than 140,000 incident reports submitted in first 5 years Success attributed

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47570/psn-pdf
     December 05, 2018 - surveillance-and Most health care organizations primarily rely on retrospective techniques such as incident … substantial proportion of patient safety events and are not effective for real-time feedback or safety incident … //psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm … https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm https … ://psnet.ahrq.gov/issue/problem-incident-reporting https://psnet.ahrq.gov/primer/triggers-and-trigger-tools

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46294/psn-pdf
     October 29, 2017 - reporting-perioperative-adverse-events-pediatric-anesthesiologists-tertiary- childrens Underreporting of adverse events is a known shortcoming of incident … to reporting and creating a local requirement to complete adverse event reports using an electronic incident … The study team concluded that mandated reporting addresses underuse of incident reporting systems. … reporting-perioperative-adverse-events-pediatric-anesthesiologists-tertiary-childrens https://psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement

477. Patients' and family members' experiences of open disclosure following adverse events. | PSNet
     psnet.ahrq.gov/issue/patients-and-family-members-experiences-open-disclosure-following-adverse-events
     September 29, 2017 - Patients' and family members' views on how clinicians enact and how they should enact incident … June 14, 2011 What prevents incident disclosure, and what can be done to promote it? … October 21, 2011 Narrativizing errors of care: critical incident reporting in clinical … June 23, 2009 Practising open disclosure: clinical incident communication and systems … June 26, 2019 Communication and Resolution After an Adverse Health Care Incident.

478. When work harms: how better understanding of avoidable employee harm can improve employee safety, patient safety and healthcare quality. | PSNet
     psnet.ahrq.gov/issue/when-work-harms-how-better-understanding-avoidable-employee-harm-can-improve-employee-safety
     December 16, 2015 - From the Same Author(s) Harms from discharge to primary care: mixed methods analysis of incident … Diagnostic error in the emergency department: learning from national patient safety incident … January 15, 2020 Characterising the nature of primary care patient safety incident reports … 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

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38308/psn-pdf
     April 21, 2010 - These results mirror concerns about standard incident- reporting systems that have been raised in prior … An accompanying editorial discusses the optimal role for incident reporting among error detection and … psnet.ahrq.gov//#safetyculture https://psnet.ahrq.gov/issue/rates-and-types-events-reported-established-incident-reporting-systems-two-us-hospitals … psnet.ahrq.gov//#incidentreporting https://psnet.ahrq.gov//#incidentreporting https://psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44382/psn-pdf
     June 21, 2016 - Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years … issue/patient-safety-reporting-qualitative-study-thoughts-and-perceptions-experts-15- years-after Incident … suggest that health systems must invest additional resources in order to attain more benefit from incident … https://psnet.ahrq.gov/primer/reporting-patient-safety-events https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm