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Showing results for "incident".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37114/psn-pdf
     October 04, 2011 - A descriptive study of morbidity and mortality conferences and their conformity to medical incident … A descriptive study of morbidity and mortality conferences and their conformity to medical incident … psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity- medical-incident … psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident … psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41066/psn-pdf
     October 16, 2012 - 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 Incident … This follow-up analysis found that incident reports were not filed for the vast majority of these adverse … https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm https

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47851/psn-pdf
     May 22, 2019 - Communication and Resolution After an Adverse Health Care Incident. … https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident Communication-and-resolution … https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident https://

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46586/psn-pdf
     January 01, 2020 - adverse-event-reporting-harnessing-residents-improve-patient-safety Physicians are known to underuse voluntary incident … physicians and simplifying their reporting system, investigators observed a 230% increase in trainee incident … A prior WebM&M commentary discussed the value of incident reporting for errors and near misses.

465. 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

466. 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

467. 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

468. 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

469. 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

470. 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

471. Health care provider use of private sector internal error-reporting systems. | PSNet
     psnet.ahrq.gov/issue/health-care-provider-use-private-sector-internal-error-reporting-systems
     May 29, 2019 - July 13, 2022 Characteristics of critical incident reporting systems in primary care: … July 26, 2011 Voluntary incident reporting by anaesthetic trainees in an Australian hospital … June 29, 2011 Implementation of a patient safety incident management system as viewed … June 15, 2011 Using incident reporting to improve patient safety: a conceptual model. … June 15, 2011 Design and implementation of an ICU incident registry.

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47090/psn-pdf
     January 01, 2019 - psnet.ahrq.gov/issue/10000-good-catches-increasing-safety-event-reporting-pediatric-health-care- system Incident … https://psnet.ahrq.gov/primer/reporting-patient-safety-events https://psnet.ahrq.gov/issue/problem-incident-reporting … https://psnet.ahrq.gov/issue/interventions-increase-clinical-incident-reporting-health-care

473. 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

474. CER 218 Evidence Summary: Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/cer-218-osteoporosis-fracture-prevention-evidence-summary.pdf
     April 01, 2019 - [95% CI 0.51, 0.85]) (moderate SOE) and incident clinical vertebral fractures (HR 0.41 [95% CI 0.22 … In women with unknown osteoporosis or osteopenia status, incident clinical fractures (high SOE) and … incident hip fractures (moderate SOE) both were reduced with hormone therapy compared to placebo, … However, these trials collectively suggested a reduction in incident vertebral fractures. … Second, only two trials were designed with incident fracture as the primary outcome.

475. CER 218 Evidence Summary: Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-218-osteoporosis-fracture-prevention-evidence-summary.pdf
     April 01, 2019 - [95% CI 0.51, 0.85]) (moderate SOE) and incident clinical vertebral fractures (HR 0.41 [95% CI 0.22 … In women with unknown osteoporosis or osteopenia status, incident clinical fractures (high SOE) and … incident hip fractures (moderate SOE) both were reduced with hormone therapy compared to placebo, … However, these trials collectively suggested a reduction in incident vertebral fractures. … Second, only two trials were designed with incident fracture as the primary outcome.

476. CER 218 Evidence Summary: Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review (pdf file)
     effectivehealthcare-admin.ahrq.gov/sites/default/files/related_files/cer-218-osteoporosis-fracture-prevention-evidence-summary.pdf
     April 01, 2019 - [95% CI 0.51, 0.85]) (moderate SOE) and incident clinical vertebral fractures (HR 0.41 [95% CI 0.22 … In women with unknown osteoporosis or osteopenia status, incident clinical fractures (high SOE) and … incident hip fractures (moderate SOE) both were reduced with hormone therapy compared to placebo, … However, these trials collectively suggested a reduction in incident vertebral fractures. … Second, only two trials were designed with incident fracture as the primary outcome.

477. 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

478. 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

479. Toward an Optimal Patient Safety Information System (TOPSIS) (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r01hs015164-koss-final-report-2008.pdf
     January 01, 2008 - 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.

480. 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