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Showing results for "incidents".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37421/psn-pdf
    February 15, 2011 - Prescription for error: process defects in a community retail pharmacy. February 15, 2011 Witte D, Dundes L. Prescription for Error. J Patient Saf. 2008;3(4). doi:10.1097/pts.0b013e31815a613e. https://psnet.ahrq.gov/issue/prescription-error-process-defects-community-retail-pharmacy This study used direct observati…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41601/psn-pdf
    August 15, 2012 - The short life and lonely death of Sabrina Seelig. August 15, 2012 Hartocollis A. https://psnet.ahrq.gov/issue/short-life-and-lonely-death-sabrina-seelig This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37402/psn-pdf
    May 07, 2008 - Patient Safety. May 7, 2008 Windle PE et al. J Perianesth Nurs. 2007;22(6):365-448. https://psnet.ahrq.gov/issue/patient-safety-24 This special issue spans a variety of safety topics pertinent to perianesthesia settings, including nurse staffing, medication error, and error reporting. https://psnet.ahrq.gov/issue…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42490/psn-pdf
    August 14, 2013 - Sentinel Event Program. August 14, 2013 Division of Licensing and Regulatory Services; Maine Department of Health and Human Services. https://psnet.ahrq.gov/issue/sentinel-event-program This Web site provides information about Maine's statewide incident reporting initiative and includes annual sentinel event repor…

  5. Template for Reports Developed (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/c-difficile-future_research.pdf
    October 26, 2012 - Template for Reports Developed Future Research Needs Paper Number 17 Future Research Needs for Prevention and Treatment of Clostridium difficile Infection Future Research Needs Paper Number 17 Future Research Needs for Prevention and Treatment of Clostridium difficile Infection Identification o…

  6. C-Diff-Infections-Surveillance-140925 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/c-diff-infections-surveillance-140925.pdf
    January 01, 2014 - AHRQ Comparative Effectiveness Review Surveillance Program CER #31: Effectiveness of Early Diagnosis, Prevention, and Treatment of Clostridium difficile Infection Original release date: December 2011 Surveillance Report (1st assessment/cycle 1): October 2012 Surveillance Report (2nd assessment/cycle 2): …

  7. Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2021 User Database Report Part II (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/Part-II-SOPS-ASC-DatabaseReport.pdf
    December 01, 2021 - from the Northeast had the highest average percentage of respondents who indicated that near-miss incidents … Anesthesiologists) or Surgeons had the highest average percentage of respondents who indicated that near-miss incidents … to 16 hours per week had the highest average percentage of respondents who indicated that near-miss incidents

  8. Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2020 User Database Report Part II (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/part-ii-sops-asc-database-report.pdf
    January 01, 2020 - geographic regions had the highest average percentage of respondents who indicated that near-miss incidents … Nurse Practitioners had the highest average percentage of respondents who indicated that near-miss incidents … to 16 hours per week had the highest average percentage of respondents who indicated that near-miss incidents

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38775/psn-pdf
    April 16, 2018 - Beyond the count: preventing the retention of foreign objects. April 16, 2018 PA-PSRS Patient Saf Advis. June 2009;6:39-45. https://psnet.ahrq.gov/issue/beyond-count-preventing-retention-foreign-objects This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36368/psn-pdf
    July 08, 2008 - Systematic review of medication errors in pediatric patients. July 8, 2008 Ghaleb M, Barber N, Franklin BD, et al. Systematic review of medication errors in pediatric patients. Ann Pharmacother. 2006;40(10):1766-76. https://psnet.ahrq.gov/issue/systematic-review-medication-errors-pediatric-patients The authors re…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35932/psn-pdf
    October 03, 2017 - Injury to research volunteers—the clinical-research nightmare. October 3, 2017 Wood AJJ, Darbyshire J. Injury to research volunteers--the clinical-research nightmare. N Engl J Med. 2006;354(18):1869-71. https://psnet.ahrq.gov/issue/injury-research-volunteers-clinical-research-nightmare The authors discuss a high-…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41681/psn-pdf
    January 01, 2013 - Patient safety in plastic surgery. September 12, 2012 Trussler AP, Tabbal GN. Patient safety in plastic surgery. Plast Reconstr Surg. 2013;130(3):470e-478e. doi:10.1097/prs.0b013e31825dc349. https://psnet.ahrq.gov/issue/patient-safety-plastic-surgery This commentary outlines tactics to prevent complications in pla…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37834/psn-pdf
    September 08, 2010 - Patient Safety in Public Hospitals. September 8, 2010 Victorian Auditor-General's Office. Melbourne, Australia: Victorian Government Printer; 2008. ISBN: 1921060689. https://psnet.ahrq.gov/issue/patient-safety-public-hospitals This report examined patient safety in public hospitals in the state of Victoria (Austra…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37990/psn-pdf
    August 13, 2008 - Most surgery in wrong spot done on spine: 11 such cases found in state since 2006. August 13, 2008 Smith S. https://psnet.ahrq.gov/issue/most-surgery-wrong-spot-done-spine-11-such-cases-found-state-2006 This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors th…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37944/psn-pdf
    April 11, 2011 - Identification of adverse events at an orthopedics department in Sweden. April 11, 2011 Unbeck M, Muren O, Lillkrona U. Identification of adverse events at an orthopedics department in Sweden. Acta Orthop. 2008;79(3):396-403. doi:10.1080/17453670710015319. https://psnet.ahrq.gov/issue/identification-adverse-events…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35591/psn-pdf
    December 21, 2005 - WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. December 21, 2005 World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2005. https://psnet.ahrq.gov/issue/who-draft-guidelines-adverse-event-reporting-and-learning-systems These guidelines present background on the…

  17. Chen, Jin | Digital Healthcare Research

    digital.ahrq.gov/principal-investigator/chen-jin
    January 01, 2023 - Chen, Jin Complexity, Incidence, and Costs Related to Delayed Diagnosis of Venous Thromboembolism in Urban and Rural Primary and Urgent Care Settings Description This research aims to improve the early detection of venous thromboembolism in primary and urgent care by using mix…

  18. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)

    www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
    January 01, 2024 - Weinger MB: Anesthesia incidents and accidents. … Gaba D, DeAnda A: The response of anesthesia trainees to simulated critical incidents. … Bothner U, Georgieff M, Schwilk B: The impact of minor perioperative anesthesia-related incidents, events

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39409/psn-pdf
    March 31, 2010 - Learning mechanisms to limit medication administration errors. March 31, 2010 Drach-Zahavy A, Pud D. Learning mechanisms to limit medication administration errors. J Adv Nurs. 2010;66(4). doi:10.1111/j.1365-2648.2010.05294.x. https://psnet.ahrq.gov/issue/learning-mechanisms-limit-medication-administration-errors …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35341/psn-pdf
    July 15, 2009 - Medical Error Reporting System Could Boost Patient Safety. July 15, 2009 Ebright PR; Rapala K. Indianapolis, IN: Center for Urban Policy and the Environment, School of Public and Environmental Affairs, Indiana University - Purdue University; 2005. https://psnet.ahrq.gov/issue/medical-error-reporting-system-could-b…
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