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Showing results for "incidents".

5001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38934/psn-pdf
      June 28, 2011 - Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System? June 28, 2011 Williams SD, Ashcroft DM. Medication errors: how reliable are the severity ratings reported to the national reporting and learning system? Int J Qual Health Care. 2009;21(5):316-20. doi:10.…

5002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44759/psn-pdf
      March 02, 2016 - Using the medication error prioritization system to improve patient safety. March 2, 2016 Polnariev A. Using the Medication Error Prioritization System To Improve Patient Safety. P T. 2016;41(1):54-9. https://psnet.ahrq.gov/issue/using-medication-error-prioritization-system-improve-patient-safety The use of incid…

5003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35635/psn-pdf
      June 24, 2010 - Patient safety problems in adolescent medical care. June 24, 2010 Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health. 2006;38(1):5-12. https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care Using data from the Colorado and Utah Medical Prac…

5004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34890/psn-pdf
      February 17, 2011 - Electronic alerts to prevent venous thromboembolism among hospitalized patients. February 17, 2011 Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352(10):969-77. https://psnet.ahrq.gov/issue/electronic-alerts-prevent-venous-thro…

5005. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837739/psn-pdf
      July 27, 2022 - Support methods for healthcare professionals who are second victims: an integrative review. July 27, 2022 Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196.  https://psnet.ahrq.gov/issue/support-methods-healthcare-professionals-who-are-second-victims-integrative- review Healthcare workers who ar…

5006. Data Collection Form | Digital Healthcare Research
      digital.ahrq.gov/document-type/data-collection-form
      January 01, 2023 - Data Collection Form ADE Incident Identification Form Description This form identifies an adverse drug event using data reported by a clinician. Document Source Statewide Implementation of Electronic Health Records ADE and Near Mis…

5007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865413/psn-pdf
      March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity March 27, 2024 Pelletreau B, Riggi J. In Conversation with..Barbara Pelletreau and John Riggi about Cybersecurity. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cyberse…

5008. Generic Dashboard Data 2024 (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
      January 01, 2024 - conditions reported by PSOs, and the extent of residual harm in patients who have experienced patient safety incidents

5009. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
      January 01, 2024 - nurse The web-based error reporting system also provided a mechanism for identifying IV medication incidents … To ensure follow-up and documentation, the IV pump nurse maintained a log of pump-related incidents … Over time, the incidents reported to the coordinator were summarized according to categories of the … This summary report facilitated organized follow up when recurring incidents or types of problems arose

5010. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
      January 01, 2024 - percutaneous injuries (i.e., injuries from needle sticks and scalpel laceration), and ‘fall-asleep’ incidents … events: 1) Direct Observation: Direct observation on morning rounds was the first method for detecting incidents … Data collected for incidents included description of the event, classification of the event, where the … Medication incidents also included name, dose, route and category of the drug involved, type of error

5011. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-version-2-resource-list.pdf
      December 01, 2024 - The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents https://www.ahrq.gov … United Kingdom determine a fair and consistent course of action toward staff involved in patient safety incidents … Survey Version 2.0 Resource List 11 open culture, where employees feel able to report patient safety incidents … and Quality Improvement The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents

5012. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
      June 14, 2023 - Look-alike medications in the perioperative setting: scoping review of medication incidents … October 11, 2023 Moving on after critical incidents in health care: a qualitative study … perspectives and experiences of second victims May 11, 2022 The impact of critical incidents … February 10, 2021 A longitudinal evaluation of computed tomography radiation incidents

5013. Head of Bed Elevation or Semirecumbent Positioning Literature Review | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/head-bed-elevation-lit-review.html
      January 01, 2017 - Head of Bed Elevation or Semirecumbent Positioning Literature Review AHRQ Safety Program for Mechanically Ventilated Patients Summary The elevation of the head of bed (HOB) to a semirecumbent position (at least 30 degrees) is associated with a decreased incidence of aspiration and ventilator-ass…

5014. Technology, Education and Safety. | PSNet
      psnet.ahrq.gov/issue/technology-education-and-safety-3
      October 11, 2023 - Special or Theme Issue Technology, Education and Safety. Citation Text: Technology, Education and Safety. Harbell MW, ed. Curr Opin Anaesthesiol. 2024;37(6):666-742. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

5015. Current and emerging infectious risks of blood transfusions. | PSNet
      psnet.ahrq.gov/issue/current-and-emerging-infectious-risks-blood-transfusions
      June 09, 2021 - Study Current and emerging infectious risks of blood transfusions. Citation Text: Busch MP, Kleinman SH, Nemo GJ. Current and emerging infectious risks of blood transfusions. JAMA. 2003;289(8):959-62. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNo…

5016. Patient Safety Organizations: Hospital Participation, Value, and Challenges. | PSNet
      psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and-challenges
      February 11, 2015 - Book/Report Patient Safety Organizations: Hospital Participation, Value, and Challenges. Citation Text: Patient Safety Organizations: Hospital Participation, Value, and Challenges. US Department of Health and Human Services; Office of the Inspector General, September 2019. OIG Report N…

5017. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. | PSNet
      psnet.ahrq.gov/issue/quality-and-economic-impact-disruptive-behaviors-clinical-outcomes-patient-care
      February 03, 2010 - Commentary The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Citation Text: Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual. 2011;26(5):372-9. doi:10.1177/106286061140…

5018. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. | PSNet
      psnet.ahrq.gov/issue/patient-safety-clinical-laboratory-longitudinal-analysis-specimen-identification-errors
      March 19, 2019 - Study Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Citation Text: Wagar EA, Tamashiro L, Yasin B, et al. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Arch Pathol Lab Med. 2…

5019. Systematic review of medication errors in pediatric patients. | PSNet
      psnet.ahrq.gov/issue/systematic-review-medication-errors-pediatric-patients
      March 05, 2010 - Review Systematic review of medication errors in pediatric patients. Citation Text: Ghaleb M, Barber N, Franklin BD, et al. Systematic review of medication errors in pediatric patients. Ann Pharmacother. 2006;40(10):1766-76. Copy Citation Format: Google Scholar PubMed Bib…

5020. Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. | PSNet
      psnet.ahrq.gov/issue/ottawa-hospital-patient-safety-study-incidence-and-timing-adverse-events-patients-admitted
      July 13, 2010 - Study Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. Citation Text: Forster AJ, Asmis TR, Clark HD, et al. Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted…