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Showing results for "incidents".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34631/psn-pdf
     December 23, 2016 - This newsletter provides guidance to health care organizations for responding to commonly reported incidents … The Joint Commission issues these sentinel event alerts to review selected incidents, determine the

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41231/psn-pdf
     March 21, 2012 - to capture reflective learning that trainees described about their experiences with patient safety incidents … issue/junior-doctors-reflections-patient-safety https://psnet.ahrq.gov/issue/debriefing-after-critical-incidents-anaesthetic-trainees

463. Near Miss with Bedside Medications | PSNet
     psnet.ahrq.gov/web-mm/near-miss-bedside-medications
     February 01, 2006 - Combining these two factors yields: (i) incidents that never reached the patient, (ii) incidents that … reached the patient but did not cause harm, and (iii) incidents that reached the patient and caused … It is desirable to have multiple channels by which frontline health care workers can report incidents … Patients and families can report near miss incidents.( 6 ) Importantly for institutions, it is not … Learning from patient-reported incidents. J Gen Intern Med. 2005;20:830-836. [go to PubMed] 7.

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40729/psn-pdf
     October 04, 2011 - critical-incident-reports-concerning-anaesthetic-equipment-analysis-uk- national-reporting-and Analysis of critical incidents … involving anesthesia equipment failure found that the vast majority of incidents did not lead to patient

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40205/psn-pdf
     April 14, 2011 - patient-safety-out-hours-primary-care-review-patient-records This study found a low rate of patient safety incidents … Most incidents were related to failures in clinical reasoning.

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46921/psn-pdf
     May 02, 2018 - This commentary reviews three medication safety incidents involving school nurses and emotional difficulties … model to help school nurses and educational leadership understand, plan for, and respond after such incidents

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37259/psn-pdf
     March 23, 2011 - tool for measuring organizational learning and provides a framework for how to assess and learn from incidents … organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance https://psnet.ahrq.gov/issue/classification-system-incidents-and-accidents-health-care-system

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35254/psn-pdf
     April 06, 2011 - Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with … detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43501/psn-pdf
     September 10, 2014 - emergency-department-patient-safety-incident-characterization-observational- analysis-findings To characterize patient safety incidents … Analysis of the data revealed that most emergency department patient safety incidents were primarily

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46409/psn-pdf
     November 08, 2017 - defining-patient-safety-hospice-principles-guide-measurement-and-public-reporting https://psnet.ahrq.gov/issue/patient-safety-incidents-home-hospice-care-experiences-hospice-interdisciplinary-team-members … https://psnet.ahrq.gov/issue/patient-reported-safety-incidents-older-patients-long-term-conditions-large-cross-sectional

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40643/psn-pdf
     July 27, 2011 - A study of the sociotechnical context through the analysis of reported medication incidents. … A study of the sociotechnical context through the analysis of reported medication incidents.

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46872/psn-pdf
     May 09, 2018 - psnet.ahrq.gov/issue/obstetric-care-consensus-no-5-severe-maternal-morbidity-screening-and- review Incidents … provides a set of diagnostic and complication screening criteria to assess severe maternal morbidity incidents

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44524/psn-pdf
     March 16, 2016 - classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents … classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37859/psn-pdf
     June 25, 2008 - the strengths and limitations of seven different sources of information on inpatient patient safety incidents … Relying on information from multiple sources is more likely to identify a broader range of incidents

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37737/psn-pdf
     January 06, 2017 - All reported incidents were reviewed by physicians to determine if a true error occurred.  … Although many incidents were reported, only a very small percentage were determined to represent true

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36244/psn-pdf
     June 13, 2012 - series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents … The majority of reported incidents were from inpatient mental health facilities, primarily involving

477. Using incident reporting to improve patient safety: a conceptual model. | PSNet
     psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model
     June 29, 2009 - Resources From the Same Author(s) A system factors analysis of "line, tube, and drain" incidents … June 29, 2009 Intensive care unit safety incidents for medical versus surgical patients … April 19, 2011 Sensitivity of routine system for reporting patient safety incidents in

478. The wisdom of patients and families: ignore it at our peril. | PSNet
     psnet.ahrq.gov/issue/wisdom-patients-and-families-ignore-it-our-peril
     March 13, 2013 - July 8, 2009 A mixed-methods analysis of patient safety incidents involving opioid substitution … October 12, 2016 Patient safety incidents involving sick children in primary care in … February 1, 2017 Deaths following prehospital safety incidents: an analysis of a national

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42252/psn-pdf
     May 08, 2013 - safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents … safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37878/psn-pdf
     February 03, 2011 - Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents … Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents