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Showing results for "incidents".

  1. Engaging patients in medication reconciliation via a patient portal following hospital discharge. | PSNet

    psnet.ahrq.gov/issue/engaging-patients-medication-reconciliation-patient-portal-following-hospital-discharge
    February 03, 2011 - Study Engaging patients in medication reconciliation via a patient portal following hospital discharge. Citation Text: Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e…

  2. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. | PSNet

    psnet.ahrq.gov/issue/iatroref-study-medical-errors-are-associated-symptoms-depression-icu-staff-not-burnout-or
    April 12, 2011 - Study The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Citation Text: Garrouste-Orgeas M, Perrin M, Soufir L, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but…

  3. Association of off-label drug use and adverse drug events in an adult population. | PSNet

    psnet.ahrq.gov/issue/association-label-drug-use-and-adverse-drug-events-adult-population
    February 03, 2011 - Study Classic Association of off-label drug use and adverse drug events in an adult population. Citation Text: Eguale T, Buckeridge DL, Verma A, et al. Association of Off-label Drug Use and Adverse Drug Events in an Adult Population. JAMA Intern Med. 2016;176(1)…

  4. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes. | PSNet

    psnet.ahrq.gov/issue/variations-gps-decisions-investigate-suspected-lung-cancer-factorial-experiment-using
    August 03, 2022 - Study Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes. Citation Text: Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia …

  5. The relationship between patients' perception of care and measures of hospital quality and safety. | PSNet

    psnet.ahrq.gov/issue/relationship-between-patients-perception-care-and-measures-hospital-quality-and-safety
    February 13, 2019 - Study Classic The relationship between patients' perception of care and measures of hospital quality and safety. Citation Text: Isaac T, Zaslavsky AM, Cleary PD, et al. The relationship between patients' perception of care and measures of hospital quality and …

  6. Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice. | PSNet

    psnet.ahrq.gov/issue/patient-doctor-continuity-and-diagnosis-cancer-electronic-medical-records-study-general
    September 11, 2019 - Study Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice. Citation Text: Ridd MJ, Ferreira DLS, Montgomery AA, et al. Patient-doctor continuity and diagnosis of cancer: electronic medical records study in general practice. Br J Gen Pra…

  7. Diagnostic errors reported in primary healthcare and emergency departments: a retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden. | PSNet

    psnet.ahrq.gov/issue/diagnostic-errors-reported-primary-healthcare-and-emergency-departments-retrospective-and
    March 11, 2020 - Study Diagnostic errors reported in primary healthcare and emergency departments: a retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden. Citation Text: Fernholm R, Pukk Härenstam K, Wachtler C, et al. Diagnostic errors reported in primary healt…

  8. Reducing hospital harm: establishing a command centre to foster situational awareness. | PSNet

    psnet.ahrq.gov/innovation/reducing-hospital-harm-establishing-command-centre-foster-situational-awareness
    June 29, 2022 - EMERGING INNOVATIONS Reducing hospital harm: establishing a command centre to foster situational awareness. Citation Text: Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885. Copy Citation …

  9. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes | PSNet

    psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
    April 10, 2024 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents

  10. In Conversation With... James Augustine, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-james-augustine-md
    July 28, 2021 - reporting. 11 , 12 , 13 , 14 Simulations are an effective technique that can help personnel learn from incidents

  11. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet

    psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
    February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857258/psn-pdf
    November 30, 2023 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon November 30, 2023 Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…

  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

  14. Hospital-Acquired Diabetic Ketoacidosis. | PSNet

    psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
    October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis. Citation Text: Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bi…

  15. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
    January 01, 2021 - Spotlight Spotlight Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Comm…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60722/psn-pdf
    February 06, 2023 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error January 11, 2022 Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error Originally published July 30, 2020. Updated January …

  17. Beyond the Hospital: the New Frontier of Patient Safety | PSNet

    psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
    August 01, 2014 - Beyond the Hospital: the New Frontier of Patient Safety Margaret Plews-Ogan, MD, MS | August 22, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet …

  18. Turn the Other Cheek | PSNet

    psnet.ahrq.gov/web-mm/turn-other-cheek
    October 26, 2010 - Turn the Other Cheek Citation Text: Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49637/psn-pdf
    October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49769/psn-pdf
    September 01, 2016 - Complaints as Safety Surveillance September 1, 2016 Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance The Case A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain came on sudden…
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