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Showing results for "incidents".

21. Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS). | PSNet
    psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural-significant-harm
    January 29, 2020 - Study Patient safety incidents in endoscopy: a human factors analysis of non-procedural … significant harm incidents from the National Reporting and Learning System (NRLS). … Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents … and Classification System coding, decision-based errors were the most common factor contributing to incidents … Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents

22. A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach. | PSNet
    psnet.ahrq.gov/issue/retrospective-review-serious-surgical-incidents-5-large-uk-teaching-hospitals-system-based
    May 26, 2021 - Study A retrospective review of serious surgical incidents in 5 large UK teaching … A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based … This study reviewed serious surgical incidents occurring at large teaching hospitals in one National … A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

23. A review of incidents related to health information technology in Swedish healthcare to characterise system issues as a basis for improvement in clinical practice. | PSNet
    psnet.ahrq.gov/issue/review-incidents-related-health-information-technology-swedish-healthcare-characterise-system
    December 20, 2023 - Study A review of incidents related to health information technology in Swedish healthcare … A review of incidents related to health information technology in Swedish healthcare to characterise … About three-quarters of the 95 incidents studied were due to technical factors. … Human factors accounted for 26% of incidents. Of all incidents, 20% led to patient harm. … A review of incidents related to health information technology in Swedish healthcare to characterise

24. Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event reporting database. | PSNet
    psnet.ahrq.gov/issue/patient-safety-trends-2022-analysis-256679-serious-events-and-incidents-nations-largest-event
    July 24, 2024 - Study Patient safety trends in 2022: an analysis of 256,679 serious events and incidents … Patient Safety Trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s … Pennsylvania requires all acute care facilities to report incidents and serious events to the Pennsylvania … Patient Safety Trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s … 2022 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents

25. Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care. | PSNet
    psnet.ahrq.gov/issue/patient-safety-incidents-during-covid-19-health-crisis-france-exploratory-sequential-multi
    February 05, 2020 - Study Patient-safety incidents during COVID-19 health crisis in France: An exploratory … Citation Text: Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential … This study examined patient safety incidents in primary care settings in France during the early months … Of the 132 reported incidents, 44% related to delayed diagnosis, assessments and referrals. … Reported incidents less commonly related to cancellation of care, home confinement-related incidents

26. Deaths following prehospital safety incidents: an analysis of a national database. | PSNet
    psnet.ahrq.gov/issue/deaths-following-prehospital-safety-incidents-analysis-national-database
    October 03, 2018 - Study Deaths following prehospital safety incidents: an analysis of a national database … Deaths following prehospital safety incidents: an analysis of a national database. … This study examined patient deaths related to ambulance safety incidents and found that the majority … Deaths following prehospital safety incidents: an analysis of a national database. … October 3, 2018 Serious incidents after death: content analysis of incidents reported

27. The impact of critical incidents on nurses and midwives: a systematic review. | PSNet
    psnet.ahrq.gov/issue/impact-critical-incidents-nurses-and-midwives-systematic-review
    May 11, 2022 - Review The impact of critical incidents on nurses and midwives: a systematic review … The impact of critical incidents on nurses and midwives: A systematic review. … This systematic review explored the experiences of critical incidents on nurses  and  midwives  and … The impact of critical incidents on nurses and midwives: A systematic review. … July 8, 2020 A scoping review of adverse incidents research in aged care homes: learnings

28. Analysis of paediatric long-term ventilation incidents in the community | PSNet
    psnet.ahrq.gov/issue/analysis-paediatric-long-term-ventilation-incidents-community
    November 06, 2024 - Study Analysis of paediatric long-term ventilation incidents in the community … Analysis of paediatric long-term ventilation incidents in the community. … The reports clearly stated harm to the child in 41% of incidents, such as emergency tracheostomy change … Analysis of paediatric long-term ventilation incidents in the community. … September 2, 2020 Reporting incidents involving the use of advanced medical technologies

29. Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement. | PSNet
    psnet.ahrq.gov/issue/learning-patient-safety-incidents-involving-acutely-sick-adults-hospital-assessment-units
    November 11, 2020 - Study Learning from patient safety incidents involving acutely sick adults in hospital … Learning from patient safety incidents involving acutely sick adults in hospital assessment units in … 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents … Learning from patient safety incidents involving acutely sick adults in hospital assessment units in … Related Resources From the Same Author(s) A mixed-methods analysis of patient safety incidents

30. Trend analysis of radiation therapy incidents over seven years. | PSNet
    psnet.ahrq.gov/issue/trend-analysis-radiation-therapy-incidents-over-seven-years
    December 20, 2023 - Study Trend analysis of radiation therapy incidents over seven years. … Trend analysis of radiation therapy incidents over seven years. … Analysis of voluntary error reports indicated a decrease in safety incidents at a high-volume radiation … Trend analysis of radiation therapy incidents over seven years.

31. Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. | PSNet
    psnet.ahrq.gov/issue/thematic-reviews-patient-safety-incidents-tool-systems-thinking-quality-improvement-report
    January 15, 2020 - Commentary Thematic reviews of patient safety incidents as a tool for systems thinking … Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report … Learning from patient safety incidents can help health care organizations improve processes and care … This article provides a template for organizations to review patient safety incidents and classify them … The process involves clearly characterizing the safety incidents, describing the involved safety systems

32. Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis. | PSNet
    psnet.ahrq.gov/issue/care-coordination-strategies-and-barriers-during-medication-safety-incidents-qualitative
    March 17, 2021 - Study Care coordination strategies and barriers during medication safety incidents … Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive … This qualitative study examined medication safety incidents at one VA hospital and found that health … Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive … February 2, 2022 The nature, severity and causes of medication incidents from an Australian

33. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. | PSNet
    psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment
    November 11, 2020 - Study Critical incidents involving the medical emergency team: a 5-year retrospective … Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare … This retrospective study analyzed critical incidents that occurred during MET responses over a five-year … Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

34. Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents. | PSNet
    psnet.ahrq.gov/issue/prosocial-voice-hierarchy-healthcare-professionals-role-emotions-after-harmful-patient-safety
    February 23, 2022 - voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents … voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents … Healthcare professionals who are involved in patient safety incidents can experience psychological … this study explored the emotional experience of healthcare professionals involved in patient safety incidents … March 8, 2023 Support for healthcare professionals after surgical patient safety incidents

35. Interventions to support nurses as second victims of patient safety incidents: a qualitative study of nurse managers' perceptions. | PSNet
    psnet.ahrq.gov/issue/interventions-support-nurses-second-victims-patient-safety-incidents-qualitative-study-nurse
    November 24, 2021 - Study Interventions to support nurses as second victims of patient safety incidents … 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 … the Same Author(s) Artificial intelligence for identifying the prevention of medication incidents … May 22, 2024 Flow of information contributing to medication incidents in home care- an

36. Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence. | PSNet
    psnet.ahrq.gov/issue/strengthening-open-disclosure-after-incidents-maternity-care-realist-synthesis-international
    September 18, 2024 - Review Strengthening open disclosure after incidents in maternity care: a realist … Strengthening open disclosure after incidents in maternity care: a realist synthesis of international … Patients and families expect full, timely disclosure after incidents. … Strengthening open disclosure after incidents in maternity care: a realist synthesis of international … March 15, 2023 Identifying no-harm incidents in home healthcare: a cohort study using

37. Learning from patient safety incidents: The Green Cross method. | PSNet
    psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method
    June 14, 2023 - Study Learning from patient safety incidents: The Green Cross method. … Learning from patient safety incidents: the Green Cross method. … A diverse array of methods exists to report and learn from patient safety incidents. … experience with the Green Cross method, a proactive method to report and learn from patient safety incidents … Learning from patient safety incidents: the Green Cross method.

38. Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. | PSNet
    psnet.ahrq.gov/issue/analysis-nature-and-contributory-factors-medication-safety-incidents-following-hospital
    October 25, 2023 - Study Analysis of the nature and contributory factors of medication safety incidents … Analysis of the nature and contributory factors of medication safety incidents following hospital discharge … Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did … Overall, most incidents occurred at the prescribing stage, but varied by patient age group. … Analysis of the nature and contributory factors of medication safety incidents following hospital discharge

39. 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database. | PSNet
    psnet.ahrq.gov/issue/2020-pennsylvania-patient-safety-reporting-analysis-serious-events-and-incidents-nations
    July 06, 2022 - Study 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … Kepner S, Jones RM. 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … Of all submitted events in 2020, 97% were from hospitals, and 97% were incidents; 3 percent were serious … October 6, 2021 Reporting incidents involving the use of advanced medical technologies … February 12, 2020 Learning from patient safety incidents involving acutely sick adults

40. Blackbox error management: how do practices deal with critical incidents in everyday practice? A qualitative interview study. | PSNet
    psnet.ahrq.gov/issue/blackbox-error-management-how-do-practices-deal-critical-incidents-everyday-practice
    May 01, 2024 - Study Blackbox error management: how do practices deal with critical incidents in … Blackbox error management: how do practices deal with critical incidents in everyday practice? … i.e., primary care, dentists, dermatology, orthopedic surgery, psychiatry/psychology) define critical incidents … Respondents described critical incidents across a spectrum, from organizational processes to medical … Blackbox error management: how do practices deal with critical incidents in everyday practice?