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Showing results for "incidents".

6441. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41657/psn-pdf
      September 26, 2012 - UTMC nurse tossed out kidney, ruined it. National experts say error is rare. September 26, 2012 Messina I. Toledo Blade. August 24, 2012. https://psnet.ahrq.gov/issue/utmc-nurse-tossed-out-kidney-ruined-it-national-experts-say-error-rare This newspaper article discusses an incident in which a transplant organ was …

6442. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45078/psn-pdf
      June 28, 2019 - Common Formats for Event Reporting. June 28, 2019 National Quality Forum. https://psnet.ahrq.gov/issue/comments-common-formats-event-reporting-hospital-version-03-beta Patient safety organizations collect data across various systems and states. This site supports review and comment of versions of common formats de…

6443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41840/psn-pdf
      November 14, 2012 - Risk Prevention and Surgical Checklists. November 14, 2012 Neurosurg Focus. 2012;33(5):E1-E16.   https://psnet.ahrq.gov/issue/risk-prevention-and-surgical-checklists This special issue includes articles discussing tactics to improve safety in neurosurgery, including tools, time-outs, and incident reporting. …

6444. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34925/psn-pdf
      February 27, 2009 - Medication errors and professional practice of registered nurses. February 27, 2009 Deans C. Medication errors and professional practice of registered nurses. Collegian. 2005;12(1):29-33. https://psnet.ahrq.gov/issue/medication-errors-and-professional-practice-registered-nurses This Australian study identified and…

6445. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41636/psn-pdf
      August 29, 2012 - Far more could be done to stop the deadly bacteria C. diff. August 29, 2012 Eisler P. USA Today. August 16, 2012. https://psnet.ahrq.gov/issue/far-more-could-be-done-stop-deadly-bacteria-c-diff This newspaper article reports on how clinicians, hospitals, and health care systems can reduce incidence of hospital-acq…

6446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38709/psn-pdf
      June 17, 2009 - Enteral feeding misconnections: an update. June 17, 2009 Guenter P, Hicks RW, Simmons D. Enteral feeding misconnections: an update. Nutr Clin Pract. 2009;24(3):325-34. doi:10.1177/0884533609335174. https://psnet.ahrq.gov/issue/enteral-feeding-misconnections-update This review surveys information on enteral nutriti…

6447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41562/psn-pdf
      August 01, 2012 - The Final Check: Say it Out Loud. August 1, 2012 https://psnet.ahrq.gov/issue/final-check-say-it-out-loud This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just culture concepts. https://psnet.ahrq.gov/issue/final-check-say-it-out-loud https://psnet.ahrq.gov/web-mm/ri…

6448. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39493/psn-pdf
      May 12, 2010 - Learning from accidents—what more do we need to know? May 12, 2010 Lindberg A-K, Hansson SO, Rollenhagen C. Learning from accidents – What more do we need to know? Saf Sci. 2010;48(6). doi:10.1016/j.ssci.2010.02.004. https://psnet.ahrq.gov/issue/learning-accidents-what-more-do-we-need-know Analyzing research on a…

6449. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60216/psn-pdf
      April 08, 2020 - The Diagnosis of Ectopic Pregnancy. April 8, 2020 Farnborough, UK:  Healthcare Safety Investigation Branch; March 2020. https://psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child. This report analyzes a dela…

6450. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36408/psn-pdf
      December 22, 2010 - Development of a rating system for surgeons' non- technical skills. December 22, 2010 Yule S, Flin R, Paterson-Brown S, et al. Development of a rating system for surgeons' non-technical skills. Med Educ. 2006;40(11):1098-104. https://psnet.ahrq.gov/issue/development-rating-system-surgeons-non-technical-skills The…

6451. Workplace Safety in Health Care | PSNet
      psnet.ahrq.gov/perspective/workplace-safety-health-care
      January 01, 2017 - We shouldn't have any accidents anymore; we should have incidents. … June 11, 2014 Miscount incidents: a novel approach to exploring risk factors for unintentionally

6452. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37099/psn-pdf
      October 04, 2011 - Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. October 4, 2011 Heck RK, O'Malley AM, Kellum EL, et al. Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions. Clin Orthop Relat Res. 2007;459:28-33. https://psnet.ahrq.gov/issue/errors-mri-evaluation-musculoskelet…

6453. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36312/psn-pdf
      October 26, 2010 - The intensive care unit, patient safety, and the Agency for Healthcare Research and Quality. October 26, 2010 Clancy CM. The intensive care unit, patient safety, and the Agency for Healthcare Research and Quality. Am J Med Qual. 2006;21(5):348-51. https://psnet.ahrq.gov/issue/intensive-care-unit-patient-safety-and…

6454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38849/psn-pdf
      January 04, 2010 - Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists. January 4, 2010 Kelly SP, Ophthalmologists RC of. Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists. Eye (Lond). 2009;23(12):2143-51. doi:10.1038/eye.2009.168. https://psnet.ahrq.gov/issue/g…

6455. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40804/psn-pdf
      November 23, 2011 - Classification and detection of errors in minimally invasive surgery. November 23, 2011 Rassweiler MC, Mamoulakis C, Kenngott HG, et al. Classification and detection of errors in minimally invasive surgery. J Endourol. 2011;25(11):1713-21. doi:10.1089/end.2011.0068. https://psnet.ahrq.gov/issue/classification-and-…

6456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37672/psn-pdf
      April 09, 2008 - An observational study of laterality errors in a sample of clinical records. April 9, 2008 Elghrably I, Fraser SG. An observational study of laterality errors in a sample of clinical records. Eye (Lond). 2008;22(3):340-3. https://psnet.ahrq.gov/issue/observational-study-laterality-errors-sample-clinical-records C…

6457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36401/psn-pdf
      December 22, 2010 - Epidemiology of medication-related adverse events in nursing homes. December 22, 2010 Handler S, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264-72. https://psnet.ahrq.gov/issue/epidemiology-medication-related-adverse-events-nu…

6458. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37330/psn-pdf
      January 05, 2012 - Unreported errors in the intensive care unit: a case study of the way we work. January 5, 2012 Henneman EA. Unreported errors in the intensive care unit: a case study of the way we work. Crit Care Nurse. 2007;27(5):27-34; quiz 35. https://psnet.ahrq.gov/issue/unreported-errors-intensive-care-unit-case-study-way-we…

6459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39780/psn-pdf
      January 04, 2017 - The First Annual HealthGrades Pediatric Patient Safety in American Hospitals Study. January 4, 2017 Reed K, May R. Golden, CO: Health Grades, Inc; 2010. https://psnet.ahrq.gov/issue/first-annual-healthgrades-pediatric-patient-safety-american-hospitals-study This report analyzed Agency for Healthcare Research and Q…

6460. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41508/psn-pdf
      July 11, 2012 - Complications in surgery: root cause analysis and preventive measures. July 11, 2012 Chung KC, Kotsis S. Complications in surgery: root cause analysis and preventive measures. Plast Reconstr Surg. 2012;129(6):1421-1427. doi:10.1097/PRS.0b013e31824ecda0. https://psnet.ahrq.gov/issue/complications-surgery-root-cause…