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Showing results for "incidents".

4201. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
      January 01, 2024 - Administration (FDA) and Institute for Safe Medication Practices (ISMP); by eliciting de-identified incidents … Sources of oral chemotherapy event reports Source Dates of Search Source Detail Number of Incidents … center 177 (25.2) 50 (25.9) 127 (25.0) Incident Reports 12/3/03 – 3/25/08 Staff-reported incidents … Incidents derived from the literature search and hospital incident reporting system included a larger … The strengths of the study include the variety of sources used to identify oral chemotherapy-related incidents

4202. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/gallagher1-report.pdf
      January 01, 2024 - in practice, put only serious-harm cases through their resolution process, we decided to make all incidents … obtained through meetings and contacts with the partner sites and analysis of case-level data on incidents … at each hospital; to compare experiences across hospitals; and to identify factors associated with incidents … Its insured physicians often did not promptly notify it when incidents occurred, and hospital risk managers … Involved personnel and their managers had difficulty getting past these incidents, and the negative

4203. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44744/psn-pdf
      June 21, 2016 - Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data. June 21, 2016 Howell A-M, Burns EM, Bouras G, et al. Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quanti…

4204. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47366/psn-pdf
      October 31, 2018 - Patient and family engagement in incident investigations: exploring hospital manager and incident investigators' experiences and challenges. October 31, 2018 Kok J, Leistikow I, Bal R. Patient and family engagement in incident investigations: exploring hospital manager and incident investigators' experiences and c…

4205. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42019/psn-pdf
      December 29, 2014 - Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting. December 29, 2014 Anderson JE, Kodate N, Walters R, et al. Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting. Int J Qual Health Care. 20…

4206. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
      April 21, 2008 - The main method used to report incidents consists of a paper incident report, which is completed by the … Incident types include medication errors, falls, procedure-related incidents, patient care-related incidents … , treatment-related incidents, equipment- related incidents, lost/broken patient articles, and other. … reported that, although labeling near misses in the pharmacy as “interventions” rather than as reportable incidents

4207. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
      March 01, 2002 - an easily accessible, confidential, Web-based reporting application for reporting patient-related incidents … However, they typically report incidents to nurses who enter the information. … report directly into this system, but they may ask nurses or other health care workers to report incidents … types and reasons could not be performed due to lack of access to charts and to persons reporting the incidents

4208. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34804/psn-pdf
      January 05, 2017 - Incident reporting system does not detect adverse drug events: a problem for quality improvement. January 5, 2017 Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-8. https://psnet.ahrq.…

4209. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853065/psn-pdf
      August 30, 2023 - Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data. August 30, 2023 Kaya GK, Ustebay S, Nixon J, et al. Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysi…

4210. Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/201411.html
      August 01, 2014 - Mercy also replaced patient beds to reduce incidents of pressure ulcers and to promote patient and staff

4211. DEcIDE 32: The Incident User Design in Comparative Effectiveness Research (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/incident-user-design_research.pdf
      May 01, 2012 - DEcIDE 32: The Incident User Design in Comparative Effectiveness Research Research from the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network May 2012 Effective Health Care Program Research Reports Number 32 The Incident User Design in Comparative Effectiveness Research Eric S. Joh…

4212. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46391/psn-pdf
      February 08, 2018 - Nature of blame in patient safety incident reports: mixed methods analysis of a national database. February 8, 2018 Cooper J, Edwards A, Williams H, et al. Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. Ann Fam Med. 2017;15(5):455-461. doi:10.1370/afm.2123. https…

4213. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44987/psn-pdf
      February 01, 2017 - International recommendations for national patient safety incident reporting systems: an expert Delphi consensus- building process. February 1, 2017 Howell A-M, Burns EM, Hull L, et al. International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process…

4214. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37612/psn-pdf
      February 15, 2011 - Can we use incident reports to detect hospital adverse events? February 15, 2011 Blais R; Bruno D; Bartlett G; Tamblyn R. https://psnet.ahrq.gov/issue/can-we-use-incident-reports-detect-hospital-adverse-events Incident reporting systems are ubiquitous, despite a lack of evidence supporting their utility in identif…

4215. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47076/psn-pdf
      August 15, 2018 - Incident learning in radiation oncology: a review. August 15, 2018 Ford E, Evans SB. Incident learning in radiation oncology: A review. Med Phys. 2018;45(5):e100-e119. doi:10.1002/mp.12800. https://psnet.ahrq.gov/issue/incident-learning-radiation-oncology-review Learning from adverse events is a core component of …

4216. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38454/psn-pdf
      January 02, 2017 - Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. January 2, 2017 Nuckols TK, Bell D, Paddock SM, et al. Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf. 2009;35(3):139-45. https://psn…

4217. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
      January 01, 2025 - word-of-mouth and ad-hoc conversations, hospital and national databases, and information from local incidents … word-of-mouth and ad-hoc conversations, hospital and national databases, and information from local incidents … The survey explored perceptions of the frequency of critical incidents in NORA, gathered descriptions … of these incidents, and examined different causes (e.g., environmental, organizational, personal, … Anaesthesia provider perceptions of system safety and critical incidents in non-operating theatre anaesthesia

4218. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/references.html
      May 01, 2023 - Contributory factors to patient safety incidents in primary care: protocol for a systematic review. … The "Seven Pillars" response to patient safety incidents: effects on medical liability processes and … Multimorbidity and patient safety incidents in primary care: a systematic review and meta-analysis. … Safety incidents in the primary care office setting. Pediatrics 2015;135(6):1027-35. … Responding to patient safety incidents: the “seven pillars.”

4219. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
      January 01, 2024 - colleagues reviewed malpractice incident reports from primary care offices.2 Though a low number of incidents … incident reporting system such as ours, which allows a more detailed examination of error-related incidents … analysis of data from secondary sources were critical for the ASIPS project to assess the specific incidents … were tested by researchers to see if they could identify consistencies or “matches” between reported incidents … Reported incidents, alone, did not provide the full picture of errors or error-related outcomes.

4220. Nursing Home Survey on Patient Safety Culture: 2019 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2019-nhsops-dbreport-parti-rev091721.pdf
      January 01, 2019 - Feedback and communication about incidents Staff discuss ways to keep residents safe, tell someone … if they see something that might harm a resident, and talk about ways to keep incidents from happening … Feedback and Communication About Incidents 85% 9.39% 54% 72% 79% 86% 92% 96% 100% 3. … Feedback and Communication About Incidents When staff report something that could harm a resident, someone … (B4) 83% 10.46% 46% 69% 76% 84% 91% 95% 100% In this nursing home, we talk about ways to keep incidents