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Showing results for "incidents".

  1. Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study. | PSNet

    psnet.ahrq.gov/issue/patient-reported-safety-incidents-older-patients-long-term-conditions-large-cross-sectional
    October 14, 2015 - Study Patient-reported safety incidents in older patients with long-term conditions … Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional … Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional … Related Resources From the Same Author(s) Multimorbidity and patient safety incidents

  2. A practical tool to learn from defects in patient care. | PSNet

    psnet.ahrq.gov/issue/practical-tool-learn-defects-patient-care
    September 28, 2010 - The authors describe a tool for investigating incidents and making necessary safety improvements. … January 20, 2010 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

  3. Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports. | PSNet

    psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2023-analysis-23970-reports
    July 08, 2020 - July 13, 2022 Patient safety trends in 2021: an analysis of 288,882 serious events and incidents … July 6, 2022 Patient safety trends in 2022: an analysis of 256,679 serious events and incidents … 2023 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … May 19, 2021 Patient safety trends in 2023: an analysis of 287,997 serious events and incidents

  4. Coworker abuse in healthcare: voices of mistreated workers. | PSNet

    psnet.ahrq.gov/issue/coworker-abuse-healthcare-voices-mistreated-workers
    March 22, 2023 - voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents … March 23, 2022 Medication safety incidents associated with the remote delivery of primary … February 15, 2023 Moving on after critical incidents in health care: a qualitative study … January 11, 2023 Moving on after critical incidents in health care: a qualitative study

  5. Feasibility of prospective error reporting in home palliative care: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/feasibility-prospective-error-reporting-home-palliative-care-mixed-methods-study
    November 11, 2020 - Related Resources From the Same Author(s) A mixed-methods analysis of patient safety incidents … Resources Multiple points of system failure underpin continuous subcutaneous infusion safety incidents … December 4, 2016 Patient safety incidents in home hospice care: the experiences of hospice … May 29, 2014 Patient safety incidents in hospice care: observations from interdisciplinary

  6. Patient safety concerns in COVID-19–related events: a study of 343 event reports from 71 hospitals in Pennsylvania. | PSNet

    psnet.ahrq.gov/issue/patient-safety-concerns-covid-19-related-events-study-343-event-reports-71-hospitals
    July 24, 2024 - July 13, 2022 Patient safety trends in 2021: an analysis of 288,882 serious events and incidents … July 6, 2022 Patient safety trends in 2022: an analysis of 256,679 serious events and incidents … 2023 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … May 19, 2021 Patient safety trends in 2023: an analysis of 287,997 serious events and incidents

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47570/psn-pdf
    December 05, 2018 - By contrast, electronic health record–based trigger tools detect safety incidents in real time. … Improvement Global Trigger Tool and distilled this into a real-time risk score for patient safety incidents … The PSAM identified 10 times more safety incidents than were detected through retrospective techniques

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47199/psn-pdf
    October 03, 2018 - Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents … Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents … In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving

  9. Improving the Value of Patient Safety Reporting Systems (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
    June 12, 2008 - A well-functioning PSRS should collect events (incidents) that could or did lead to patient harm. … In essence, incidents should be used as golden nuggets of data to address and fix a specific hazard … This was one of many cases found when the ICUSRS team reviewed incidents to evaluate underreporting … How to place incidents into taxonomies? … Understanding incidents in the aggregate requires a classification of those incidents.

  10. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-420
    November 29, 2023 - Study Blackbox error management: how do practices deal with critical incidents … Respondents described critical incidents across a spectrum, from organizational processes to medical … Study Blackbox error management: how do practices deal with critical incidents … Respondents described critical incidents across a spectrum, from organizational processes to medical … Nearly 45% of incidents reached the patient without causing harm, but 8.4% resulted in patient harm.

  11. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-325
    January 07, 2022 - Reporting patient safety incidents is essential to improving patient safety. … This study compared the number of self-reported (to the study team) safety incidents during interhospital … transport and the number of incidents submitted to the hospital’s reporting system. … Reporting patient safety incidents is essential to improving patient safety. … transport and the number of incidents submitted to the hospital’s reporting system.

  12. Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths | PSNet

    psnet.ahrq.gov/issue/using-who-international-classification-patient-safety-framework-identify-incident
    January 15, 2020 - December 15, 2021 A mixed-methods analysis of patient safety incidents involving opioid … October 12, 2016 Patient safety incidents involving sick children in primary care in … September 24, 2017 Safety incidents in the primary care office setting. … July 3, 2016 Patient safety incidents in advance care planning for serious illness: a

  13. Analysis of results from event investigations in industrial and patient safety contexts. | PSNet

    psnet.ahrq.gov/issue/analysis-results-event-investigations-industrial-and-patient-safety-contexts
    July 06, 2022 - Same Author(s) Patient safety trends in 2021: an analysis of 288,882 serious events and incidents … 2021 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … June 29, 2022 Learning from patient safety incidents involving acutely sick adults in … March 30, 2022 Artificial intelligence for identifying the prevention of medication incidents

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45562/psn-pdf
    October 12, 2016 - This publication explored primary care incidents reported in England and Wales over an 8-year period … inconsistencies and gaps in information collected, including a lack of defined reasons explaining why incidents … Despite weaknesses in the data, they were able to categorize the types of incidents and prioritize system

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862153/psn-pdf
    February 07, 2024 - 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

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862620/psn-pdf
    February 14, 2024 - https://psnet.ahrq.gov/issue/look-alike-medications-perioperative-setting-scoping-review-medication-incidents-and-risk … https://psnet.ahrq.gov/issue/look-alike-medications-perioperative-setting-scoping-review-medication-incidents-and-risk

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866247/psn-pdf
    July 10, 2024 - Most incidents were medication-related, followed by patient falls, and incidents related to venous thromboembolism

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866561/psn-pdf
    August 21, 2024 - researchers found that the spring transition to DST was not associated with higher severity patient safety incidents … sleep-and-circadian-misalignment-hospitalist-review https://psnet.ahrq.gov/issue/increased-patient-safety-related-incidents-following-transition-daylight-savings-time

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867748/psn-pdf
    March 12, 2025 - This study analyzed 145 safety incidents related to telehealth at the VHA. … The largest category was delays in care, and 90% of incidents resulted in no harm.

  20. PSOPPC: Nursing Home

    Research Study
    www.psoppc.org/psoppc_web/publicpages/nursinghomeV1.0
    March 14, 2025 - Patient safety concerns for the Device category include incidents, near misses, and unsafe conditions … Patient safety events for the Fall category include only incidents that occur in a nursing home.     … Patient safety concerns for the Medication or Other Substance category include incidents, near misses … Patient safety events for the Pressure Injury (Pressure Ulcer) category include only incidents that occur … Generic Flow Charts The following section contains the Common Formats Flow Charts for incidents, near
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