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Showing results for "incidents".

101. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. | PSNet
     psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national
     December 16, 2015 - This publication explored primary care incidents reported in England and Wales over an 8-year period … December 16, 2015 Safety incidents in the primary care office setting. … July 3, 2016 Patient safety incidents involving sick children in primary care in England … November 16, 2016 A mixed-methods analysis of patient safety incidents involving opioid … March 15, 2017 Patient Safety: Investigating and Reporting Serious Clinical Incidents

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/862130/psn-pdf
     February 07, 2024 - Interventions to support nurses as second victims of patient safety incidents: a qualitative study of … Interventions to support nurses as second victims of patient safety incidents: a qualitative study of … https://psnet.ahrq.gov/issue/interventions-support-nurses-second-victims-patient-safety-incidents- qualitative-study-nurse … require support (often referred to as the second victim phenomenon) after involvement in patient safety incidents … interventions and suggest that standardized support, such as full team debriefing after all patient safety incidents

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866642/psn-pdf
     September 04, 2024 - Learning from patient safety incidents: The Green Cross method. … Learning from patient safety incidents: the Green Cross method. … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method A diverse array of … methods exists to report and learn from patient safety incidents. … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method https://psnet.ahrq.gov

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866349/psn-pdf
     July 24, 2024 - A multifaceted risk management program to improve the reporting rate of patient safety incidents in … A multifaceted risk management program to improve the reporting rate of patient safety incidents in … //psnet.ahrq.gov/issue/multifaceted-risk-management-program-improve-reporting-rate-patient-safety- incidents-primary … identification of a risk management advisor, and multidisciplinary meetings focused on patient safety incidents … https://psnet.ahrq.gov/issue/blackbox-error-management-how-do-practices-deal-critical-incidents-everyday-practice

105. Patient safety in primary allied health care: what can we learn from incidents in a Dutch exploratory cohort study? | PSNet
     psnet.ahrq.gov/issue/patient-safety-primary-allied-health-care-what-can-we-learn-incidents-dutch-exploratory
     March 02, 2022 - Study Patient safety in primary allied health care: what can we learn from incidents … Patient safety in primary allied health care: what can we learn from incidents in a Dutch exploratory … Patient safety in primary allied health care: what can we learn from incidents in a Dutch exploratory … June 3, 2020 Classification of medication incidents associated with information technology … February 10, 2021 System issues leading to "found-on-floor" incidents: a multi-incident

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72823/psn-pdf
     March 10, 2021 - Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive … Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive … https://psnet.ahrq.gov/issue/care-coordination-strategies-and-barriers-during-medication-safety-incidents … This qualitative study examined medication safety incidents at one VA hospital and found that health … decision-making, back-up behaviors, and contingency planning to coordinate care during medication safety incidents

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866693/psn-pdf
     September 11, 2024 - Care home safety incidents and safeguarding reports relating to hospital to care home transitions: a … Care home safety incidents and safeguarding reports relating to hospital to care home transitions: a … https://psnet.ahrq.gov/issue/care-home-safety-incidents-and-safeguarding-reports-relating-hospital-care … Common incidents included pressure injuries, medication errors, and premature discharge. … https://psnet.ahrq.gov/issue/care-home-safety-incidents-and-safeguarding-reports-relating-hospital-care-home-transitions

108. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/858163/psn-pdf
     December 13, 2023 - Blackbox error management: how do practices deal with critical incidents in everyday practice? … Blackbox error management: how do practices deal with critical incidents in everyday practice? … https://psnet.ahrq.gov/issue/blackbox-error-management-how-do-practices-deal-critical-incidents-everyday … ., primary care, dentists, dermatology, orthopedic surgery, psychiatry/psychology) define critical incidents … Respondents described critical incidents across a spectrum, from organizational processes to medical

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73181/psn-pdf
     April 28, 2021 - Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare … Critical incidents involving the medical emergency team: a 5- year retrospective assessment for healthcare … https://psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective … This retrospective study analyzed critical incidents that occurred during MET responses over a five-year … https://psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment

110. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837634/psn-pdf
     July 06, 2022 - Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s … Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s … https://psnet.ahrq.gov/issue/patient-safety-trends-2021-analysis-288882-serious-events-and-incidents- … nations-largest-event Acute care facilities in Pennsylvania are required to report all Incidents and … https://psnet.ahrq.gov/issue/2020-pennsylvania-patient-safety-reporting-analysis-serious-events-and-incidents-nations

111. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73917/psn-pdf
     October 06, 2021 - Reporting of health information technology system- related patient safety incidents: the effects of … Reporting of health information technology system-related patient safety incidents: the effects of organizational … https://psnet.ahrq.gov/issue/reporting-health-information-technology-system-related-patient-safety- incidents-effects … Organizational culture can influence whether or not clinicians report patient safety incidents. … surveyed about their experiences with non-reporting of health information technology (HIT)-related safety incidents

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73168/psn-pdf
     April 21, 2021 - Patient safety incidents describing patient falls in critical care in North West England between 2009 … Patient safety incidents describing patient falls in critical care in North West England between 2009 … https://psnet.ahrq.gov/issue/patient-safety-incidents-describing-patient-falls-critical-care-north-west … The authors reviewed patient safety incidents in critical care units in England between 2009 and 2017 … Common factors involved in fall incidents included patients attempting tasks without assistance, patient

113. What is learning? A review of the safety literature to define learning from incidents, accidents and disasters. | PSNet
     psnet.ahrq.gov/issue/what-learning-review-safety-literature-define-learning-incidents-accidents-and-disasters
     December 17, 2010 - A review of the safety literature to define learning from incidents, accidents and disasters. … A Review of the Safety Literature to Define Learning from Incidents, Accidents and Disasters. … key processes to ensure the effectiveness of this method , including face-to-face discussions about incidents … A Review of the Safety Literature to Define Learning from Incidents, Accidents and Disasters. … April 11, 2011 Medication safety incidents associated with the remote delivery of primary

114. The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008. | PSNet
     psnet.ahrq.gov/issue/non-technical-skills-used-anaesthetic-technicians-critical-incidents-reported-australian
     January 19, 2011 - Study The non-technical skills used by anaesthetic technicians in critical incidents … The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian … of these skills played a role in ameliorating these events, while lack of these skills exacerbated incidents … The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian … July 31, 2008 Safety in anaesthesia: a study of 12,606 reported incidents from the UK

115. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73497/psn-pdf
     July 14, 2021 - Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury … Health care workers’ experiences of workplace incidents that posed a risk of patient and worker injury … https://psnet.ahrq.gov/issue/health-care-workers-experiences-workplace-incidents-posed-risk-patient-and … workers in Sweden, the authors explored how individuals, team members and managers respond to critical incidents … Critical incidents are emotionally distressing for healthcare workers but teamwork and trust among teams

116. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836984/psn-pdf
     April 27, 2022 - A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in … A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in … https://psnet.ahrq.gov/issue/6-year-thematic-review-reported-incidents-associated-cardiopulmonary- resuscitation-calls … https://psnet.ahrq.gov/issue/6-year-thematic-review-reported-incidents-associated-cardiopulmonary-resuscitation-calls … https://psnet.ahrq.gov/issue/critical-incidents-related-cardiac-arrests-reported-danish-patient-safety-database

117. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849329/psn-pdf
     May 24, 2023 - Interorganizational health information exchange-related patient safety incidents: a descriptive register-based … Interorganizational health information exchange-related patient safety incidents: a descriptive register-based … https://psnet.ahrq.gov/issue/interorganizational-health-information-exchange-related-patient-safety- incidents-descriptive … identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents … The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61114/psn-pdf
     November 11, 2020 - A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone … methods analysis of patient safety incidents involving opioid substitution treatment with methadone … https://psnet.ahrq.gov/issue/mixed-methods-analysis-patient-safety-incidents-involving-opioid-substitution … England and Wales, this study analyzed 2,284 patient safety incident reports and found that harmful incidents … – such as not following protocols, poor continuity of care – contributed to more than half of the incidents

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849129/psn-pdf
     November 01, 2023 - Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s … Patient Safety Trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s … https://psnet.ahrq.gov/issue/patient-safety-trends-2022-analysis-256679-serious-events-and-incidents- … nations-largest-event Pennsylvania requires all acute care facilities to report incidents and serious … https://psnet.ahrq.gov/issue/patient-safety-trends-2022-analysis-256679-serious-events-and-incidents-nations-largest-event

120. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/850161/psn-pdf
     June 07, 2023 - Analysis of the nature and contributory factors of medication safety incidents following hospital discharge … Analysis of the nature and contributory factors of medication safety incidents following hospital discharge … https://psnet.ahrq.gov/issue/analysis-nature-and-contributory-factors-medication-safety-incidents-following … Patients over 65 were the most common age group and, of incidents with a stated level of harm, most … Overall, most incidents occurred at the prescribing stage, but varied by patient age group.