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Total Results: over 10,000 records

Showing results for "incidents".

4641. Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization. | PSNet
      psnet.ahrq.gov/issue/self-reported-learning-srl-voluntary-incident-reporting-system-experience-within-large-health
      October 26, 2022 - Study Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization. Citation Text: Lurvey LD, Fassett MJ, Kanter MH. Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organiz…

4642. The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements. | PSNet
      psnet.ahrq.gov/issue/fusion-incident-learning-and-failure-mode-and-effects-analysis-data-driven-patient-safety
      November 17, 2021 - Study The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements. Citation Text: Paradis KC, Naheedy KW, Matuszak MM, et al. The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improve…

4643. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45210/psn-pdf
      September 27, 2016 - Increased risk of burnout for physicians and nurses involved in a patient safety incident. September 27, 2016 Van Gerven E, Elst TV, Vandenbroeck S, et al. Increased Risk of Burnout for Physicians and Nurses Involved in a Patient Safety Incident. Med Care. 2016;54(10):937-943. doi:10.1097/MLR.0000000000000582. ht…

4644. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/848754
      January 01, 2025 - factors for effective implementation of healthcare workers support interventions after patient safety incidents … factors for effective implementation of healthcare workers support interventions after patient safety incidents

4645. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/guides/implguide-refs.html
      October 01, 2015 - A nurse-driven Foley catheter removal protocol proves clinically effective to reduce the incidents of

4646. Ambulatory Procedure/Surgery Center Survey on Patient Safety (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-survey-english.docx
      June 02, 2025 - Such prevention includes reducing mistakes, errors, incidents, events, or problems that lead to patient

4647. TeamSTEPPS Research/Evidence Base: Teams in Health Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/evidence-base/teams.html
      June 01, 2023 - Learning from safety incidents in high-reliability organizations: A systematic review of learning tools

4648. Teamwork Training | PSNet
      psnet.ahrq.gov/primer/teamwork-training
      September 15, 2024 - Debriefing  and providing feedback, especially after critical incidents, are essential components of

4649. Disclosure of Errors | PSNet
      psnet.ahrq.gov/primer/disclosure-errors
      September 15, 2024 - Surgery December 15, 2024 Editor's Picks Strengthening open disclosure after incidents

4650. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33568/psn-pdf
      June 15, 2024 - perspective/rethinking-root-cause-analysis https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents

4651. CER 218 Evidence Summary: Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-218-osteoporosis-fracture-prevention-evidence-summary.pdf
      April 01, 2019 - CER 218 Evidence Summary: Long-Term Drug Therapy and Drug Holidays for Osteoporosis Fracture Prevention: A Systematic Review Purpose of Review To summarize the effects of long-term osteoporosis drug treatment and of osteoporosis drug treatment discontinuation and holidays. Key Messages • Evidence on the effects …

4652. Chapter 5 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
      August 01, 2022 - will analyze trends and conduct aggregate causal analysis, but may also evaluate selected individual incidents … development of any public reporting program will include decisions regarding reporting of individuals incidents

4653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49497/psn-pdf
      December 01, 2005 - Whether or not simulation-based training in and of itself prevents incidents such as the ones described … The most frequent contributing factor to these incidents is deficient behavioral skills.

4654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49783/psn-pdf
      February 01, 2017 - is an understandable human reaction, but doing so does nothing to address the root causes of these incidents … checklists contain a list of items to be followed in all circumstances without leading to adverse incidents

4655. The Other Side | PSNet
      psnet.ahrq.gov/web-mm/other-side
      May 01, 2007 - need for apology, explanation, and assurance that preventative action has been taken against future incidents … How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and

4656. Duplicate Insulin Order | PSNet
      psnet.ahrq.gov/web-mm/duplicate-insulin-order
      May 04, 2012 - 30% resulting in hospital admission.( 2 ) One report described 16,600 insulin-related patient safety incidents … Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety

4657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47648/psn-pdf
      February 27, 2019 - Comparing the outcomes of reporting and trigger tool methods to capture adverse events in the emergency department. February 27, 2019 Lee W-H, Zhang E, Chiang C-Y, et al. Comparing the Outcomes of Reporting and Trigger Tool Methods to Capture Adverse Events in the Emergency Department. J Patient Saf. 2019;15(1):61…

4658. The incidence and preventability of adverse events in older acutely admitted patients: a longitudinal study with 4292 patient records. | PSNet
      psnet.ahrq.gov/issue/incidence-and-preventability-adverse-events-older-acutely-admitted-patients-longitudinal
      June 08, 2022 - Study The incidence and preventability of adverse events in older acutely admitted patients: a longitudinal study with 4292 patient records. Citation Text: Schouten B, Merten H, Spreeuwenberg PMM, et al. The incidence and preventability of adverse events in older acutely admitted patient…

4659. The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. | PSNet
      psnet.ahrq.gov/issue/nature-causes-and-clinical-impact-errors-clinical-laboratory-testing-process-leading
      May 18, 2022 - Study The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. Citation Text: van Moll C, Egberts TCG, Wagner C, et al. The nature, causes, and clinical impact of errors in the clinical…

4660. Developing a Passive Digital Marker for the Prediction of Childhood Asthma Treatment Response | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/developing-passive-digital-marker-prediction-childhood-asthma-treatment
      July 31, 2025 - Developing a Passive Digital Marker for the Prediction of Childhood Asthma Treatment Response Project Description Publications Applying novel machine learning methodologies in real time to readily available risk and prognostic data in electronic health records could contr…