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Showing results for "incidents".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47299/psn-pdf
     March 20, 2019 - unintentionally-retained-guidewires-descriptive-study-73-sentinel-events This retrospective review examines incidents … The authors conclude that multicomponent strategies to prevent incidents involving retained foreign

462. Blood Dashboard Data (xls file)
     www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/Blood_Dashboard_Data_2023.xlsx
     January 01, 2023 - * 8497 Lymphocytes * * 8497 NOTE: The 'Percentage' cells are calculated as the percentage of all incidents … NOTE: The 'No Harm Percentage' and 'Harm Percentage' cells are calculated as the percentage of all incidents … 3,637 Unknown 17.7% 645 3,637 NOTE: The 'Percentage' cells are calculated as the percentage of all incidents … NOTE: The 'No Harm Percentage' and 'Harm Percentage' cells are calculated as the percentage of all incidents … 4,220 Unknown 15.5% 656 4,220 NOTE: The Percentage cells are calculated as the percentage of all incidents

463. Medication or Other Substance Supplement Dashboard | Agency for Healthcare Research and Quality
     pcmh.ahrq.gov/npsd/data/dashboard/medication-supplement.html
     September 01, 2023 - including description of substance event, stage event originated, and type of substance involved for incidents … , near misses, and unsafe conditions, then further examines incidents and near misses along with their

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855431/psn-pdf
     January 01, 2024 - The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents … The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36604/psn-pdf
     June 04, 2024 - Since 2003, Minnesota hospitals have been required to report such incidents. … Unintentionally-retained foreign objects and fall-related injuries were common incidents recorded.

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846148/psn-pdf
     March 15, 2023 - //psnet.ahrq.gov/issue/near-miss-events-detected-using-emergency-department-trigger-tool Near-miss incidents … This study used a computerized trigger tool to identify near-miss incidents in the emergency department

467. Clear liquids may place patients at risk. | PSNet
     psnet.ahrq.gov/issue/clear-liquids-may-place-patients-risk
     May 19, 2021 - Author(s) 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents … September 9, 2011 Reporting of health information technology system-related patient safety incidents … August 3, 2022 Medication safety in mental health hospitals: a mixed-methods analysis of incidents

468. Integrating the intensive care unit safety reporting system with existing incident reporting systems. | PSNet
     psnet.ahrq.gov/issue/integrating-intensive-care-unit-safety-reporting-system-existing-incident-reporting-systems
     January 12, 2011 - January 12, 2011 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 … January 15, 2014 Intensive care unit safety incidents for medical versus surgical patients … October 26, 2010 Medication-related patient safety incidents in critical care: a review

469. Preventable adverse drug events and their causes and contributing factors: the analysis of register data. | PSNet
     psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors-analysis-register
     August 01, 2016 - August 19, 2020 An analysis of electronic health record–related patient safety incidents … August 3, 2017 Reporting of health information technology system-related patient safety incidents … patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents … September 14, 2022 Artificial intelligence for identifying the prevention of medication incidents

470. Changes in physician practice patterns after implementation of a communication-and-resolution program. | PSNet
     psnet.ahrq.gov/issue/changes-physician-practice-patterns-after-implementation-communication-and-resolution-program
     September 01, 2018 - Related Resources From the Same Author(s) The "Seven Pillars" response to patient safety incidents … September 20, 2011 Successful remediation of patient safety incidents: a tale of two … December 4, 2016 Responding to patient safety incidents: the "seven pillars." … October 24, 2018 The "Seven Pillars" response to patient safety incidents: effects on

471. Harm caused by adverse events in primary care: a clinical observational study. | PSNet
     psnet.ahrq.gov/issue/harm-caused-adverse-events-primary-care-clinical-observational-study
     July 23, 2008 - June 2, 2010 Classification of medication incidents associated with information technology … January 7, 2015 Patient safety in primary allied health care: what can we learn from incidents … Are health professionals' perceptions of patient safety related to figures on safety incidents … Are health professionals' perceptions of patient safety related to figures on safety incidents

472. Identification of adverse events at an orthopedics department in Sweden. | PSNet
     psnet.ahrq.gov/issue/identification-adverse-events-orthopedics-department-sweden
     May 08, 2013 - May 8, 2013 Identifying no-harm incidents in home healthcare: a cohort study using trigger … January 25, 2023 Occurrence of no-harm incidents and adverse events in hospitalized patients … February 21, 2018 Development of a trigger tool to identify adverse events and no-harm incidents … safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844777/psn-pdf
     September 18, 2019 - Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents … Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents

474. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-301
     July 28, 2021 - Study Patient-safety incidents during COVID-19 health crisis in France: An exploratory … 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, … 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,

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34631/psn-pdf
     December 23, 2016 - This newsletter provides guidance to health care organizations for responding to commonly reported incidents … The Joint Commission issues these sentinel event alerts to review selected incidents, determine the

476. Harms from discharge to primary care: mixed methods analysis of incident reports. | PSNet
     psnet.ahrq.gov/issue/harms-discharge-primary-care-mixed-methods-analysis-incident-reports
     October 12, 2016 - October 12, 2016 Patient safety incidents involving sick children in primary care in … February 1, 2017 Safety incidents in the primary care office setting. … December 15, 2021 A mixed-methods analysis of patient safety incidents involving opioid … December 16, 2020 Classification of patient-safety incidents in primary care.

477. Nature of blame in patient safety incident reports: mixed methods analysis of a national database. | PSNet
     psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national-database
     October 12, 2016 - October 12, 2016 Classification of patient-safety incidents in primary care. … December 16, 2015 Patient safety incidents involving sick children in primary care in … February 1, 2017 Safety incidents in the primary care office setting. … September 24, 2017 A mixed-methods analysis of patient safety incidents involving opioid

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41231/psn-pdf
     March 21, 2012 - to capture reflective learning that trainees described about their experiences with patient safety incidents … issue/junior-doctors-reflections-patient-safety https://psnet.ahrq.gov/issue/debriefing-after-critical-incidents-anaesthetic-trainees

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33716/psn-pdf
     September 01, 2011 - Shojania: The most plausible hope was that by analyzing certain types of incidents, that you could learn … Incident reporting was designed to identify important incidents that need to be investigated ASAP, so … or identify incidents that need a quick or timely investigation. … It's tempting to want to pool across these incidents and then across institutions. … Whereas a lot of other incidents and serious things like wrong- site surgery where there will be so

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49639/psn-pdf
     November 01, 2011 - Combining these two factors yields: (i) incidents that never reached the patient, (ii) incidents that … reached the patient but did not cause harm, and (iii) incidents that reached the patient and caused … Reporting systems allow incidents to be analyzed in terms of contributing factors and to follow trends … It is desirable to have multiple channels by which frontline health care workers can report incidents … Learning from patient-reported incidents. J Gen Intern Med. 2005;20:830-836. [go to PubMed] 7.