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Showing results for "incidents".

301. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
     December 01, 2003 - The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents 387 The Incident … Research shows that systems failures are the root cause of the majority of safety incidents. … • Improving understanding of the causes of adverse incidents and near incidents. … It is estimated that up to half of all incidents may be preventable.1 The way in which such incidents … • The majority of incidents appear to involve protocol violation.

302. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38414/psn-pdf
     March 31, 2009 - Patient safety incidents associated with airway devices in critical care: a review of reports to the … Patient safety incidents associated with airway devices in critical care: a review of reports to the … https://psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports … https://psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports-uk-national … https://psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports-uk-national

303. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46513/psn-pdf
     June 19, 2018 - Development of a trigger tool to identify adverse events and no-harm incidents that affect patients … Development of a trigger tool to identify adverse events and no-harm incidents that affect patients … https://psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-no-harm-incidents-affect … https://psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-no-harm-incidents-affect-patients … https://psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-no-harm-incidents-affect-patients

304. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37648/psn-pdf
     January 12, 2012 - Office surgery incidents: what seven years of Florida data show us. … Office surgery incidents: what seven years of Florida data show us. … https://psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us Patient … The majority of deaths and hospital transfers occurred in patients undergoing cosmetic procedures, incidents … https://psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us https://psnet.ahrq.gov

305. Toward learning from patient safety reporting systems. | PSNet
     psnet.ahrq.gov/issue/toward-learning-patient-safety-reporting-systems
     January 02, 2017 - developed through funding by the Agency for Healthcare Research and Quality (AHRQ), collected data on incidents … A substantial minority (42%) of incidents led to patient harm, and most had multiple contributing factors … January 2, 2017 A system factors analysis of "line, tube, and drain" incidents in the … June 29, 2009 Intensive care unit safety incidents for medical versus surgical patients … August 25, 2010 Pediatric safety incidents from an intensive care reporting system.

306. Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database. | PSNet
     psnet.ahrq.gov/issue/quality-improvement-priorities-safer-out-hours-palliative-care-lessons-mixed-methods-analysis
     July 03, 2016 - Incidents related to medications were common, accounting for 613 out of the 1072 safety events included … Download Citation Related Resources From the Same Author(s) Safety incidents … July 3, 2016 Patient safety incidents in advance care planning for serious illness: a … April 1, 2020 Patient safety incidents involving sick children in primary care in England … February 1, 2017 Classification of patient-safety incidents in primary care.

307. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45293/psn-pdf
     February 01, 2017 - Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods … Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods … https://psnet.ahrq.gov/issue/patient-safety-incidents-involving-sick-children-primary-care-england-and … They found that about one third of 2191 safety incidents represented cases of severe harm. … https://psnet.ahrq.gov/issue/patient-safety-incidents-involving-sick-children-primary-care-england-and-wales-mixed-methods

308. Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. | PSNet
     psnet.ahrq.gov/issue/critical-incidents-related-cardiac-arrests-reported-danish-patient-safety-database
     February 18, 2015 - Study Critical incidents related to cardiac arrests reported to the Danish Patient … Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. … Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database. … April 29, 2020 View More Related Resources Critical incidents involving … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

309. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39427/psn-pdf
     July 30, 2012 - Responding to patient safety incidents: the "seven pillars." … Responding to patient safety incidents: the "seven pillars". … https://psnet.ahrq.gov/issue/responding-patient-safety-incidents-seven-pillars This article describes … https://psnet.ahrq.gov/issue/responding-patient-safety-incidents-seven-pillars https://psnet.ahrq.gov

310. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35662/psn-pdf
     June 25, 2010 - Debriefing after critical incidents for anaesthetic trainees. June 25, 2010 Tan H. … Debriefing after critical incidents for anaesthetic trainees. … https://psnet.ahrq.gov/issue/debriefing-after-critical-incidents-anaesthetic-trainees The author surveyed … https://psnet.ahrq.gov/issue/debriefing-after-critical-incidents-anaesthetic-trainees https://psnet.ahrq.gov

311. Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process. | PSNet
     psnet.ahrq.gov/issue/equipment-related-incidents-operating-room-analysis-occurrence-underlying-causes-and
     February 14, 2024 - Study Equipment-related incidents in the operating room: an analysis of occurrence … Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences … Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences … March 4, 2009 View More Related Resources Patient safety incidents

312. Suicide risk, changing jobs, or leaving the nursing profession in the aftermath of a patient safety incident. | PSNet
     psnet.ahrq.gov/issue/suicide-risk-changing-jobs-or-leaving-nursing-profession-aftermath-patient-safety-incident
     July 22, 2020 - jobs, consider leaving the profession, and have suicidal ideation , compared to nurses involved in incidents … Peer support by interprofessional health care providers in aftermath of patient safety incidents … June 9, 2021 A mixed-methods analysis of patient safety incidents involving opioid substitution … factors for effective implementation of healthcare workers support interventions after patient safety incidents

313. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. | PSNet
     psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report
     January 12, 2022 - The majority of incidents (86%) were delayed diagnoses; the remainder were wrong diagnoses. … December 16, 2015 A mixed-methods analysis of patient safety incidents involving opioid … December 16, 2020 Learning from patient safety incidents involving acutely sick adults … August 25, 2021 Classification of patient-safety incidents in primary care.

314. Anticipating patient safety events in psychiatric care. | PSNet
     psnet.ahrq.gov/issue/anticipating-patient-safety-events-psychiatric-care
     March 10, 2021 - In this retrospective study, researchers evaluated safety incidents reported using the Psychiatry Morbidity … Reporting Tool (PMMIRT) and proposed a revised categorization to better understand the types of safety incidents … July 6, 2022 Reduced postdischarge incidents after implementation of a hospital-to-home … 2023 Patients who die by suicide: a study of treatment patterns and patient safety incidents

315. Register-based research of adverse events revealing incomplete records threatening patient safety. | PSNet
     psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
     October 06, 2021 - This retrospective review of patient incident reports in Finland found that nearly half of the 82,353 incidents … Same Author(s) Reporting of health information technology system-related patient safety incidents … January 25, 2023 Critical incidents involving the medical emergency team: a 5-year retrospective … April 28, 2021 Learning from safety incidents in high reliability organizations: a systematic

316. Classification of health information technology safety events in a pediatric tertiary care hospital. | PSNet
     psnet.ahrq.gov/issue/classification-health-information-technology-safety-events-pediatric-tertiary-care-hospital
     May 20, 2019 - For incidents to be properly addressed, incident reports must be appropriately identified and categorized … This study compared the categorization of incidents as involving health information technology (HIT) … Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents … managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents

317. Characteristics of critical incident reporting systems in primary care: an international survey. | PSNet
     psnet.ahrq.gov/issue/characteristics-critical-incident-reporting-systems-primary-care-international-survey
     September 07, 2022 - of this study was to support future implementation of CIRS in primary care by discussing types of incidents … that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting … Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents … September 11, 2013 Safety incidents in family medicine.

318. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35024/psn-pdf
     March 04, 2011 - Excellent review scheme for critical incidents but insufficient for revalidation. … Excellent review scheme for critical incidents but insufficient for revalidation. … https://psnet.ahrq.gov/issue/excellent-review-scheme-critical-incidents-insufficient-revalidation The … https://psnet.ahrq.gov/issue/excellent-review-scheme-critical-incidents-insufficient-revalidation https

319. Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. | PSNet
     psnet.ahrq.gov/issue/interpreting-adverse-drug-reaction-adr-reports-hospital-patient-safety-incidents
     August 04, 2021 - Study Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents … Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. … Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. … November 12, 2008 Medication-related patient safety incidents in critical care: a review

320. Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. | PSNet
     psnet.ahrq.gov/issue/barriers-self-reporting-patient-safety-incidents-paramedics-mixed-methods-study
     November 16, 2022 - Study Barriers to self-reporting patient safety incidents by paramedics: a mixed … Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study. … Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study. … September 17, 2018 Reportable incidents.