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Showing results for "incidents".

  1. In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. | PSNet

    psnet.ahrq.gov/issue/hospital-mortality-associated-misdiagnosis-or-unidentified-site-infection-admission
    June 27, 2011 - Review In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. Citation Text: Abe T, Tokuda Y, Shiraishi A, et al. In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission. Crit Care. 2019;23(1):2…

  2. Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. | PSNet

    psnet.ahrq.gov/issue/goals-and-priorities-health-care-organizations-improve-safety-using-health-it-revised-report
    May 13, 2015 - Book/Report Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. Citation Text: Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. Graber ML, Bailey R, Johnston D. RTI International; Washi…

  3. Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. | PSNet

    psnet.ahrq.gov/issue/prospective-observational-study-incidence-medication-errors-during-simulated-resuscitation
    April 22, 2011 - Study Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. Citation Text: Kozer E, Seto W, Verjee Z, et al. Prospective observational study on the incidence of medication errors during simulated resus…

  4. Checking all the boxes: a checklist for when and how to use checklists effectively. | PSNet

    psnet.ahrq.gov/issue/checking-all-boxes-checklist-when-and-how-use-checklists-effectively
    June 29, 2022 - Commentary Checking all the boxes: a checklist for when and how to use checklists effectively. Citation Text: Alfred M, Barg-Walkow LH, Keebler JR, et al. Checking all the boxes: a checklist for when and how to use checklists effectively. BMJ Qual Saf. 2024;33(10):673-681. doi:10.1136/bm…

  5. Interruptions and distractions in healthcare: review and reappraisal. | PSNet

    psnet.ahrq.gov/issue/interruptions-and-distractions-healthcare-review-and-reappraisal
    January 19, 2011 - Review Classic Interruptions and distractions in healthcare: review and reappraisal. Citation Text: Rivera-Rodriguez AJ, Karsh B-T. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care. 2010;19(4):304-312. doi:10.1136/qshc.2…

  6. Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. | PSNet

    psnet.ahrq.gov/issue/creating-spaces-intensive-care-safe-communication-video-reflexive-ethnographic-study
    December 18, 2013 - Study Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. Citation Text: Hor S-Y, Iedema R, Manias E. Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study. BMJ Qual Saf. 2014;23(12):1007-13. doi:10.1136…

  7. Health care professionals' views of implementing a policy of open disclosure of errors. | PSNet

    psnet.ahrq.gov/issue/health-care-professionals-views-implementing-policy-open-disclosure-errors
    September 29, 2017 - Study Health care professionals' views of implementing a policy of open disclosure of errors. Citation Text: Sorensen R, Iedema R, Piper D, et al. Health care professionals' views of implementing a policy of open disclosure of errors. J Health Serv Res Policy. 2008;13(4):227-32. doi:10.1…

  8. Doctors' stress responses and poor communication performance in simulated bad-news consultations. | PSNet

    psnet.ahrq.gov/issue/doctors-stress-responses-and-poor-communication-performance-simulated-bad-news-consultations
    July 19, 2023 - Study Doctors' stress responses and poor communication performance in simulated bad-news consultations. Citation Text: Brown R, Dunn S, Byrnes K, et al. Doctors' stress responses and poor communication performance in simulated bad-news consultations. Acad Med. 2009;84(11):1595-602. doi…

  9. Disclosing clinical adverse events to patients: can practice inform policy? | PSNet

    psnet.ahrq.gov/issue/disclosing-clinical-adverse-events-patients-can-practice-inform-policy
    September 29, 2017 - Study Disclosing clinical adverse events to patients: can practice inform policy? Citation Text: Sorensen R, Iedema R, Piper D, et al. Disclosing clinical adverse events to patients: can practice inform policy? Health Expect. 2010;13(2):148-59. doi:10.1111/j.1369-7625.2009.00569.x. Cop…

  10. Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery. | PSNet

    psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent-problems-patient
    March 18, 2020 - Study Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery. Citation Text: Anderson DE, Watts B. Application of an engineering problem-solving methodology to address persistent…

  11. Radiology research in quality and safety: current trends and future needs. | PSNet

    psnet.ahrq.gov/issue/radiology-research-quality-and-safety-current-trends-and-future-needs
    November 16, 2022 - Review Radiology research in quality and safety: current trends and future needs. Citation Text: Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021. Copy …

  12. Elucidating reasons for resident underutilization of electronic adverse event reporting. | PSNet

    psnet.ahrq.gov/issue/elucidating-reasons-resident-underutilization-electronic-adverse-event-reporting
    November 21, 2021 - Study Elucidating reasons for resident underutilization of electronic adverse event reporting. Citation Text: Hatoun J, Suen W, Liu C, et al. Elucidating Reasons for Resident Underutilization of Electronic Adverse Event Reporting. Am J Med Qual. 2016;31(4):308-314. doi:10.1177/1062860615…

  13. Designing and implementing a comprehensive quality and patient safety management model: a paradigm for perioperative improvement. | PSNet

    psnet.ahrq.gov/issue/designing-and-implementing-comprehensive-quality-and-patient-safety-management-model-paradigm
    March 01, 2011 - Study Designing and implementing a comprehensive quality and patient safety management model: a paradigm for perioperative improvement. Citation Text: Herzer KR, Mark LJ, Michelson JD, et al. Designing and Implementing a Comprehensive Quality and Patient Safety Management Model. J Pati…

  14. A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-clinical-error-confronting-disjunction-between-formal-rules-and-situated
    June 14, 2011 - Commentary A root cause analysis of clinical error: confronting the disjunction between formal rules and situated clinical activity. Citation Text: Iedema RAM, Jorm C, Braithwaite J, et al. A root cause analysis of clinical error: confronting the disjunction between formal rules and si…

  15. Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. | PSNet

    psnet.ahrq.gov/issue/experiences-health-professionals-who-conducted-root-cause-analyses-after-undergoing-safety
    June 14, 2011 - Study Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Citation Text: Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root cause analyses after undergoing a safety im…

  16. Draft Recommendation: Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Falls and Fractures in Community-Dwelling Adults: Preventive Medication | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/vitamin-d-calcium-combined-supplementation-primary-prevention-falls-fractures-communitydwelling-adults
    December 17, 2024 - Share to Facebook Share to X Share to WhatsApp Share to Email Print in progress Draft Recommendation Statement Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Falls and Fractures in Community-Dwelling Adults: Pre…

  17. Use of Medications to Reduce Risk for Primary Breast Cancer: A Systematic Review of the USPSTF (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/7ZSKduUYHWKe7q_tTY9xbF
    April 01, 2013 - Use of Medications to Reduce Risk for Primary Breast Cancer: A Systematic Review of the USPSTF Use of Medications to Reduce Risk for Primary Breast Cancer: A Systematic Review for the U.S. Preventive Services Task Force Heidi D. Nelson, MD, MPH; M.E. Beth Smith, DO; Jessica C. Griffin, MS; and Rongwei Fu, PhD Backgr…

  18. Archived: C-Reactive Protein as a Risk Factor for Coronary Heart Disease: A Systematic Review and Meta-analyses for the U.S. Preventive Services Task Force: Coronary Heart Disease: Screening Using Non-Traditional Risk Factors | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/document/c-reactive-protein-as-a-risk-factor-for-coronary-heart-disease-a-systematic-review-and-meta-analyses-for-the-us-preventive-services-task-force/coronary-heart-disease-screening-using-non-traditional-risk-factors-2009
    July 15, 2008 - Share to Facebook Share to X Share to WhatsApp Share to Email Print archived C-Reactive Protein as a Risk Factor for Coronary Heart Disease: A Systematic Review and Meta-analyses for the U.S. Preventive Services Task Force Coronary Heart Disease:…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61062/psn-pdf
    January 01, 2022 - Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. October 28, 2020 Duffy CC, Bass GA, Duncan JR, et al. Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error a…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866646/psn-pdf
    September 04, 2024 - Adverse events and perceived abandonment: learning from patients' accounts of medical mishaps. September 4, 2024 Schlesinger M, Dhingra I, Fain BA, et al. Adverse events and perceived abandonment: learning from patients’ accounts of medical mishaps. BMJ Open Qual. 2024;13(3):e002848. doi:10.1136/bmjoq-2024- 002848…
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