Results

Total Results: over 10,000 records

Showing results for "incidents".

401. Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports. | PSNet
     psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2023-analysis-23970-reports
     July 08, 2020 - July 13, 2022 Patient safety trends in 2021: an analysis of 288,882 serious events and incidents … July 6, 2022 Patient safety trends in 2022: an analysis of 256,679 serious events and incidents … 2023 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … May 19, 2021 Patient safety trends in 2023: an analysis of 287,997 serious events and incidents

402. Feasibility of prospective error reporting in home palliative care: a mixed methods study. | PSNet
     psnet.ahrq.gov/issue/feasibility-prospective-error-reporting-home-palliative-care-mixed-methods-study
     November 11, 2020 - Related Resources From the Same Author(s) A mixed-methods analysis of patient safety incidents … Resources Multiple points of system failure underpin continuous subcutaneous infusion safety incidents … December 4, 2016 Patient safety incidents in home hospice care: the experiences of hospice … May 29, 2014 Patient safety incidents in hospice care: observations from interdisciplinary

403. Learning from excellence in healthcare: a new approach to incident reporting. | PSNet
     psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
     August 31, 2022 - June 12, 2008 Patient safety incidents in advance care planning for serious illness: … December 6, 2013 Review of patient safety incidents reported from critical care units … November 17, 2010 Patient safety incidents associated with equipment in critical care … June 10, 2010 Medication-related patient safety incidents in critical care: a review

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34778/psn-pdf
     December 23, 2008 - The discussion continues by contrasting incidents and accidents and the cognitive processes involved … The authors recommend greater emphasis on detecting simple incidents, using simulators to promote education … and training, detailing backup equipment, and disseminating effective protocols for particular incidents

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34982/psn-pdf
     July 14, 2010 - The investigators aimed to create an easy-to-use system that assists in characterizing captured incidents … includes details of the design features, a table of the system-based factors contributing to reported incidents … after implementation demonstrated wide variability in use, but consistency existed in the types of incidents

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45351/psn-pdf
     July 20, 2016 - patient-safety-toolkit-general-practice https://psnet.ahrq.gov/primer/ambulatory-care-safety https://psnet.ahrq.gov/issue/safety-incidents-primary-care-office-setting … https://psnet.ahrq.gov/issue/safety-incidents-primary-care-office-setting https://psnet.ahrq.gov/primer … psnet.ahrq.gov/primer/medication-reconciliation https://psnet.ahrq.gov/issue/investigating-clinical-incidents-nhs

407. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33932/psn-pdf
     May 27, 2011 - preventable-anesthesia-mishaps-study-human-factors This study reports on the retrospective analysis of nearly 360 preventable incidents … Findings attributed the majority of incidents to human error, with a relatively small percentage due … The authors suggest that their method of examining incidents may be effective to help pool similar data

408. The Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach. | PSNet
     psnet.ahrq.gov/issue/orthopaedic-error-index-development-and-application-novel-national-indicator-assessing
     July 18, 2016 - December 16, 2015 Safety incidents in the primary care office setting. … July 3, 2016 A mixed-methods analysis of patient safety incidents involving opioid substitution … November 11, 2020 Patient safety incidents involving sick children in primary care in … February 1, 2017 Classification of patient-safety incidents in primary care. … safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents

409. Developing agreement on never events in primary care dentistry: an international eDelphi study. | PSNet
     psnet.ahrq.gov/issue/developing-agreement-never-events-primary-care-dentistry-international-edelphi-study
     October 05, 2016 - Download Citation Related Resources From the Same Author(s) Patient safety incidents … December 16, 2020 A mixed-methods analysis of patient safety incidents involving opioid … October 12, 2016 Patient safety incidents involving sick children in primary care in … September 24, 2017 Safety incidents in the primary care office setting. … October 19, 2016 Safety incidents in the primary care office setting.

410. Patient safety concerns in COVID-19–related events: a study of 343 event reports from 71 hospitals in Pennsylvania. | PSNet
     psnet.ahrq.gov/issue/patient-safety-concerns-covid-19-related-events-study-343-event-reports-71-hospitals
     July 24, 2024 - July 13, 2022 Patient safety trends in 2021: an analysis of 288,882 serious events and incidents … July 6, 2022 Patient safety trends in 2022: an analysis of 256,679 serious events and incidents … 2023 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … May 19, 2021 Patient safety trends in 2023: an analysis of 287,997 serious events and incidents

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33931/psn-pdf
     June 23, 2015 - The authors describe characteristics from more than 1000 incidents collected and offer strategies to … the patterns noted, the discussion suggests that human error played a dominant role in the reported incidents … The authors conclude that it may be beneficial to classify specific incidents by a preventive strategy

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34706/psn-pdf
     December 23, 2012 - Of the 805 incidents reported, 76% were qualitatively judged to be preventable and 27% to have the potential … The authors provide a detailed breakdown of the types of incidents, factors that mitigated the harm … caused by the incidents, and demographics of the affected patients.

413. Adverse events and near misses relating to information management in a hospital. | PSNet
     psnet.ahrq.gov/issue/adverse-events-and-near-misses-relating-information-management-hospital
     December 29, 2014 - These incidents were often due to workarounds, such as recording patient information on paper instead … August 19, 2020 An analysis of electronic health record–related patient safety incidents … August 3, 2017 Reporting of health information technology system-related patient safety incidents

414. Preventable anesthesia mishaps: a study of human factors. | PSNet
     psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors
     June 23, 2015 - This study reports on the retrospective analysis of nearly 360 preventable incidents at an urban teaching … Findings attributed the majority of incidents to human error, with a relatively small percentage due … The authors suggest that their method of examining incidents may be effective to help pool similar data

415. Surgical never events in the United States. | PSNet
     psnet.ahrq.gov/issue/surgical-never-events-united-states
     September 10, 2014 - Despite public uproar and attention focused on these never events , such incidents continue to occur … January 20, 2010 A system factors analysis of "line, tube, and drain" incidents in the … June 29, 2009 Intensive care unit safety incidents for medical versus surgical patients

416. Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths | PSNet
     psnet.ahrq.gov/issue/using-who-international-classification-patient-safety-framework-identify-incident
     January 15, 2020 - December 15, 2021 A mixed-methods analysis of patient safety incidents involving opioid … October 12, 2016 Patient safety incidents involving sick children in primary care in … September 24, 2017 Safety incidents in the primary care office setting. … July 3, 2016 Patient safety incidents in advance care planning for serious illness: a

417. Analysis of results from event investigations in industrial and patient safety contexts. | PSNet
     psnet.ahrq.gov/issue/analysis-results-event-investigations-industrial-and-patient-safety-contexts
     July 06, 2022 - Same Author(s) Patient safety trends in 2021: an analysis of 288,882 serious events and incidents … 2021 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … June 29, 2022 Learning from patient safety incidents involving acutely sick adults in … March 30, 2022 Artificial intelligence for identifying the prevention of medication incidents

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47199/psn-pdf
     October 03, 2018 - Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents … Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents … In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867748/psn-pdf
     March 12, 2025 - This study analyzed 145 safety incidents related to telehealth at the VHA. … The largest category was delays in care, and 90% of incidents resulted in no harm.

420. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45562/psn-pdf
     October 12, 2016 - This publication explored primary care incidents reported in England and Wales over an 8-year period … inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents … Despite weaknesses in the data, they were able to categorize the types of incidents and prioritize system