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Showing results for "incident".

  1. Human error: models and management. | PSNet

    psnet.ahrq.gov/issue/human-error-models-and-management
    November 18, 2015 - Commentary Classic Human error: models and management. Citation Text: Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

  2. Textbook of Rapid Response Systems: Concept and Implementation. | PSNet

    psnet.ahrq.gov/issue/textbook-rapid-response-systems-concept-and-implementation
    September 30, 2010 - Book/Report Textbook of Rapid Response Systems: Concept and Implementation. Citation Text: Textbook Of Rapid Response Systems: Concept And Implementation. (DeVita MA, ed.). Springer; 2025. ISBN 9783031679513. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  3. Is failure mode and effect analysis reliable? | PSNet

    psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable
    August 15, 2012 - Study Is failure mode and effect analysis reliable? Citation Text: Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Patient Saf. 2009;5(2):86-94. doi:10.1097/PTS.0b013e3181a6f040. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNo…

  4. I'm sorry: laws that support apologies in health care. | PSNet

    psnet.ahrq.gov/issue/im-sorry-laws-support-apologies-health-care
    March 11, 2020 - Commentary I'm sorry: laws that support apologies in health care. Citation Text: Atkinson Smith M. Iʼm Sorry. Prof Case Manag. 2019;25(1):40-45. doi:10.1097/ncm.0000000000000410. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  5. Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. | PSNet

    psnet.ahrq.gov/issue/reducing-risks-wrong-site-surgery-safety-practices-joint-commission-center-transforming
    October 19, 2016 - Book/Report Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. Citation Text: Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project. Chi…

  6. Medical Device Use Error: Root Cause Analysis. | PSNet

    psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
    January 10, 2018 - Book/Report Medical Device Use Error: Root Cause Analysis. Citation Text: Medical Device Use Error: Root Cause Analysis. Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. Copy Citation Save Save to your library Print Down…

  7. Integrating human factors research and surgery: a review. | PSNet

    psnet.ahrq.gov/issue/integrating-human-factors-research-and-surgery-review
    August 02, 2015 - Review Integrating human factors research and surgery: a review. Citation Text: Shouhed D, Gewertz BL, Wiegmann D, et al. Integrating human factors research and surgery: a review. Arch Surg. 2012;147(12):1141-1146. doi:10.1001/jamasurg.2013.596. Copy Citation Format: DOI Go…

  8. Use of cascading A3s to drive systemwide improvement. | PSNet

    psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-improvement
    January 29, 2015 - Commentary Use of cascading A3s to drive systemwide improvement. Citation Text: Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011. Copy Citation Format: …

  9. The second victim: a review. | PSNet

    psnet.ahrq.gov/issue/second-victim-review
    June 26, 2019 - Review The second victim: a review. Citation Text: Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNot…

  10. Seeking answers, hearing silence. | PSNet

    psnet.ahrq.gov/issue/seeking-answers-hearing-silence
    October 09, 2024 - Commentary Seeking answers, hearing silence. Citation Text: Hemmelgarn C. Seeking Answers, Hearing Silence. Health Aff (Millwood). 2018;37(8):1332-1334. doi:10.1377/hlthaff.2017.1535. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnot…

  11. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. | PSNet

    psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
    May 30, 2012 - Multi-use Website Classic Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Citation Text: Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The Joint Commission. Copy Citation …

  12. Health information technology-related wrong-patient errors: context is critical. | PSNet

    psnet.ahrq.gov/issue/health-information-technology-related-wrong-patient-errors-context-critical
    June 01, 2022 - Study Health information technology-related wrong-patient errors: context is critical. Citation Text: Health information technology-related wrong-patient errors: context is critical. Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.    Copy Citation …

  13. Preventive Care | Digital Healthcare Research

    digital.ahrq.gov/type-care/preventive-care
    January 01, 2023 - Preventive Care A Longitudinal Machine Learning Approach Providing Clinicians Timely Detection to Prevent Military Suicide Description This research will develop and validate a clinician-facing longitudinal risk-prediction tool using self-reported data from US military service…

  14. Inability of providers to predict unplanned readmissions. | PSNet

    psnet.ahrq.gov/issue/inability-providers-predict-unplanned-readmissions
    December 05, 2007 - Study Inability of providers to predict unplanned readmissions. Citation Text: Allaudeen N, Schnipper JL, Orav J, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011;26(7):771-6. doi:10.1007/s11606-011-1663-3. Copy Citation Format: DOI Go…

  15. The development of the National Reporting and Learning System in England and Wales, 2001-2005. | PSNet

    psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005
    September 14, 2022 - Commentary The development of the National Reporting and Learning System in England and Wales, 2001-2005. Citation Text: Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…

  16. Rapid response systems as a patient safety strategy: a systematic review. | PSNet

    psnet.ahrq.gov/issue/rapid-response-systems-patient-safety-strategy-systematic-review
    March 20, 2013 - Review Rapid response systems as a patient safety strategy: a systematic review. Citation Text: Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051…

  17. Hospital performance trends on national quality measures and the association with Joint Commission accreditation. | PSNet

    psnet.ahrq.gov/issue/hospital-performance-trends-national-quality-measures-and-association-joint-commission
    September 20, 2011 - Study Hospital performance trends on national quality measures and the association with Joint Commission accreditation. Citation Text: Schmaltz SP, Williams SC, Chassin MR, et al. Hospital performance trends on national quality measures and the association with joint commission accre…

  18. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. | PSNet

    psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
    February 10, 2012 - Review Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. Citation Text: Zahiri HR, Stromberg J, Skupsky H, et al. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. Surg Innov. 2011;18(1):55-…

  19. Information distortion in physicians' diagnostic judgments. | PSNet

    psnet.ahrq.gov/issue/information-distortion-physicians-diagnostic-judgments
    April 07, 2021 - Study Information distortion in physicians' diagnostic judgments. Citation Text: Kostopoulou O, Russo E, Keenan G, et al. Information distortion in physicians' diagnostic judgments. Med Decis Making. 2012;32(6):831-9. doi:10.1177/0272989X12447241. Copy Citation Format: DO…

  20. Using an automated risk assessment report to identify patients at risk for clinical deterioration. | PSNet

    psnet.ahrq.gov/issue/using-automated-risk-assessment-report-identify-patients-risk-clinical-deterioration
    February 15, 2017 - Commentary Using an automated risk assessment report to identify patients at risk for clinical deterioration. Citation Text: Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Jt Comm J Qual Patient S…
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