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Showing results for "incidents".

  1. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. | PSNet

    psnet.ahrq.gov/issue/disclosing-large-scale-adverse-events-us-veterans-health-administration-lessons-media
    August 18, 2021 - Study Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. Citation Text: Maguire EM, Bokhour BG, Asch SM, et al. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses. Public …

  2. Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative. | PSNet

    psnet.ahrq.gov/issue/amid-covid-19-pandemic-meaningful-communication-between-family-caregivers-and-residents-long
    May 26, 2011 - Commentary Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative. Citation Text: Hado E, Friss Feinberg L. Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of lon…

  3. When bad things happen: training medical students to anticipate the aftermath of medical errors. | PSNet

    psnet.ahrq.gov/issue/when-bad-things-happen-training-medical-students-anticipate-aftermath-medical-errors
    July 29, 2020 - Study When bad things happen: training medical students to anticipate the aftermath of medical errors. Citation Text: Musunur S, Waineo E, Walton E, et al. When bad things happen: training medical students to anticipate the aftermath of medical errors. Acad Psychiatry. 2020;44(5):586-591…

  4. Hospital readmission and parent perceptions of their child's hospital discharge. | PSNet

    psnet.ahrq.gov/issue/hospital-readmission-and-parent-perceptions-their-childs-hospital-discharge
    July 03, 2016 - Study Hospital readmission and parent perceptions of their child's hospital discharge. Citation Text: Berry JG, Ziniel SI, Freeman L, et al. Hospital readmission and parent perceptions of their child's hospital discharge. Int J Qual Health Care. 2013;25(5):573-81. doi:10.1093/intqhc/mzt0…

  5. Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. | PSNet

    psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
    August 02, 2015 - Commentary Emerging Classic Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem. Citation Text: Rosenbaum L. Divided We Fall. N Engl J Med. 2019;380(7):684-688. doi:10…

  6. Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians. | PSNet

    psnet.ahrq.gov/issue/pediatric-musculoskeletal-radiographs-anatomy-and-fractures-prone-diagnostic-error-among
    March 24, 2021 - Study Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians. Citation Text: Li W, Stimec J, Camp M, et al. Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians. J Emer…

  7. Antibiotic-resistant infection treatment costs have doubled since 2002, now exceeding $2 billion annually. | PSNet

    psnet.ahrq.gov/issue/antibiotic-resistant-infection-treatment-costs-have-doubled-2002-now-exceeding-2-billion
    July 02, 2019 - Study Classic Antibiotic-resistant infection treatment costs have doubled since 2002, now exceeding $2 billion annually. Citation Text: Thorpe KE, Joski P, Johnston KJ. Antibiotic-Resistant Infection Treatment Costs Have Doubled Since 2002, Now Exceeding $2 Bill…

  8. Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. | PSNet

    psnet.ahrq.gov/issue/determination-unnecessary-blood-transfusion-comprehensive-15-hospital-record-review
    October 27, 2021 - Study Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. Citation Text: Jadwin DF, Fenderson PG, Friedman MT, et al. Determination of unnecessary blood transfusion by comprehensive 15-hospital record review. Jt Comm J Qual Patient Saf. 2023;49(1):4…

  9. Nosocomial SARS-CoV-2 infections and mortality during unique COVID-19 epidemic waves. | PSNet

    psnet.ahrq.gov/issue/nosocomial-sars-cov-2-infections-and-mortality-during-unique-covid-19-epidemic-waves
    February 14, 2024 - Study Nosocomial SARS-CoV-2 infections and mortality during unique COVID-19 epidemic waves. Citation Text: Dave N, Sjöholm D, Hedberg P, et al. Nosocomial SARS-CoV-2 infections and mortality during unique COVID-19 epidemic waves. JAMA Netw Open. 2023;6(11):e2341936. doi:10.1001/jamanetwo…

  10. Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. | PSNet

    psnet.ahrq.gov/issue/why-do-healthcare-professionals-fail-escalate-early-warning-system-ews-protocol-qualitative
    August 25, 2021 - Review Emerging Classic Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. Citation Text: O’Neill SM, Clyne B, Bell M, et al. Why do h…

  11. Impact of automated alerts on discharge opioid overprescribing after general surgery. | PSNet

    psnet.ahrq.gov/issue/impact-automated-alerts-discharge-opioid-overprescribing-after-general-surgery
    September 29, 2017 - Study Impact of automated alerts on discharge opioid overprescribing after general surgery. Citation Text: Rizk E, Kaur N, Duong PY, et al. Impact of automated alerts on discharge opioid overprescribing after general surgery. Am J Health Syst Pharm. 2024;81(24):1288-1296. doi:10.1093/ajh…

  12. Primary care closed claims experience of Massachusetts malpractice insurers. | PSNet

    psnet.ahrq.gov/issue/primary-care-closed-claims-experience-massachusetts-malpractice-insurers
    August 14, 2017 - Study Classic Primary care closed claims experience of Massachusetts malpractice insurers. Citation Text: Schiff G, Puopolo AL, Huben-Kearney A, et al. Primary care closed claims experience of Massachusetts malpractice insurers. JAMA Intern Med. 2013;173(22):206…

  13. Identifying patient and practice characteristics associated with patient-reported experiences of safety problems and harm: a cross-sectional study using a multilevel modelling approach. | PSNet

    psnet.ahrq.gov/issue/identifying-patient-and-practice-characteristics-associated-patient-reported-experiences
    April 25, 2018 - Study Identifying patient and practice characteristics associated with patient-reported experiences of safety problems and harm: a cross-sectional study using a multilevel modelling approach. Citation Text: Ricci-Cabello I, Reeves D, Bell BG, et al. Identifying patient and practice chara…

  14. An objective framework for evaluating unrecognized bias in medical AI models predicting COVID-19 outcomes. | PSNet

    psnet.ahrq.gov/issue/objective-framework-evaluating-unrecognized-bias-medical-ai-models-predicting-covid-19
    July 22, 2020 - Study An objective framework for evaluating unrecognized bias in medical AI models predicting COVID-19 outcomes. Citation Text: Estiri H, Strasser ZH, Rashidian S, et al. An objective framework for evaluating unrecognized bias in medical AI models predicting COVID-19 outcomes. J Am Med I…

  15. Systematic root cause analysis of adverse drug events in a tertiary referral hospital. | PSNet

    psnet.ahrq.gov/issue/systematic-root-cause-analysis-adverse-drug-events-tertiary-referral-hospital
    November 16, 2022 - Study Classic Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Citation Text: Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. Jt Comm J Qual Improv…

  16. Understanding the nature of medication errors in an ICU with a computerized physician order entry system. | PSNet

    psnet.ahrq.gov/issue/understanding-nature-medication-errors-icu-computerized-physician-order-entry-system
    August 24, 2015 - Study Understanding the nature of medication errors in an ICU with a computerized physician order entry system. Citation Text: Cho IS, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a computerized physician order entry system. PLoS One. 2014;9(12):e1…

  17. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. | PSNet

    psnet.ahrq.gov/issue/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
    May 12, 2021 - Commentary The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Citation Text: Kanter MH, Ghobadi A, Lurvey LD, et al. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Diagnosis (Berl). 2022;9(4):430-43…

  18. Frequency and outcome of cervical cancer prevention failures in the United States. | PSNet

    psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states
    April 09, 2013 - Study Frequency and outcome of cervical cancer prevention failures in the United States. Citation Text: Raab SS, Grzybicki DM, Zarbo RJ, et al. Frequency and outcome of cervical cancer prevention failures in the United States. Am J Clin Pathol. 2007;128(5):817-24. Copy Citation F…

  19. Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID-19. | PSNet

    psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system-resilience-case-covid
    February 16, 2022 - Study Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID-19. Citation Text: Albutt AK, Ramsey L, Fylan B, et al. Patient and public co‐creation of healthcare safety and healthcare system resilience: the case of COVID‐19. Health Expect.…

  20. System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model. | PSNet

    psnet.ahrq.gov/issue/system-hazards-managing-laboratory-test-requests-and-results-primary-care-medical-protection
    November 08, 2017 - Study System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model. Citation Text: Bowie P, Price J, Hepworth N, et al. System hazards in managing laboratory test requests and results in primary care: medical p…
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