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Showing results for "incidents".

  1. Amphotericin Toxicity | PSNet

    psnet.ahrq.gov/web-mm/amphotericin-toxicity
    April 01, 2014 - Amphotericin Toxicity Citation Text: Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

  2. Checklist for Working with the KID

    hcup-us.ahrq.gov/db/nation/kid/kidchecklist.jsp
    September 01, 2025 - Checklist for Working with the KID An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Update…

  3. Checklist for Working with the NRD

    hcup-us.ahrq.gov/db/nation/nrd/nrdchecklist.jsp
    November 01, 2024 - Checklist for Working with the NRD An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Update…

  4. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/74277
    January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

  5. Clinical-Care-Rapid-Review-Appendix-C (xls file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/clinical-care-rapid-review-appendix-c.xlsx
    January 01, 2018 - The "Seven Pillars" Response to Patient Safety Incidents: Effects on Medical Liability Processes and … Hospital and Health Sciences System Study setting: Health system Patient population: Unclear n = 637 incidents … review communication Attorney involvement: Compensation process: NA NA NA NA "Efficiently respond to incidents … of clear medical error with….efforts at quality improvement" General: "Efficiently respond to incidents … Non-preventable events: NA Preventable events: NA NA NA "Efficiently respond to incidents of clear medical

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866863/psn-pdf
    October 02, 2024 - The nature of adverse events in dentistry. October 2, 2024 Tokede B, Yansane A, Walji MF, et al. The nature of adverse events in dentistry. J Patient Saf. 2024;20(7):454-460. doi:10.1097/pts.0000000000001255. https://psnet.ahrq.gov/issue/nature-adverse-events-dentistry Patient safety in dentistry is relatively und…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47966/psn-pdf
    May 29, 2019 - Patient Safety Essentials Toolkit. May 29, 2019 Boston, MA: Institute for Healthcare Improvement; 2019. https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43538/psn-pdf
    September 17, 2014 - Medication errors: an overview for clinicians. September 17, 2014 Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc. 2014;89(8):1116-25. doi:10.1016/j.mayocp.2014.05.007. https://psnet.ahrq.gov/issue/medication-errors-overview-clinicians Medication safety is an ongoing…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46039/psn-pdf
    April 05, 2017 - Retained lumbar catheter tip. April 5, 2017 DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270. doi:10.1001/jama.2017.1713. https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip Retained surgical items are considered a sentinel event. Discussing an incident involvi…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43396/psn-pdf
    July 30, 2014 - Patient safety and quality care. July 30, 2014 Nelson K. Patient safety and quality care. Clin Dermatol. 2014;32(4):542-4. doi:10.1016/j.clindermatol.2013.12.001. https://psnet.ahrq.gov/issue/patient-safety-and-quality-care This commentary reveals insights from a physician who was involved in a misidentified speci…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40311/psn-pdf
    March 23, 2011 - The association of shift-level nurse staffing with adverse patient events. March 23, 2011 Patrician PA, Loan L, McCarthy MC, et al. The association of shift-level nurse staffing with adverse patient events. J Nurs Adm. 2011;41(2):64-70. doi:10.1097/NNA.0b013e31820594bf. https://psnet.ahrq.gov/issue/association-shi…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44613/psn-pdf
    October 28, 2015 - Getting rid of "never events" in hospitals. October 28, 2015 Morgenthaler T; Harper CM. https://psnet.ahrq.gov/issue/getting-rid-never-events-hospitals Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them. This commentary discusses how the Mayo…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43437/psn-pdf
    August 13, 2014 - Diagnostic error: untapped potential for improving patient safety? August 13, 2014 Groszkruger D. Diagnostic error: untapped potential for improving patient safety? J Healthc Risk Manag. 2014;34(1):38-43. doi:10.1002/jhrm.21149. https://psnet.ahrq.gov/issue/diagnostic-error-untapped-potential-improving-patient-saf…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42291/psn-pdf
    September 12, 2016 - Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. September 12, 2016 Acquaviva K, Haskell H, Johnson J. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. J Prof Nurs. 2013;29(2):95-101. doi:10.1016/j.profnurs.2012.12.009. https://psnet.ahrq.gov/issue/huma…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44007/psn-pdf
    April 01, 2015 - Time to tackle diagnostic errors. Physicians blame patient 'treadmill' for missed calls. April 1, 2015 Rice S. Time to tackle diagnostic errors. Physicians blame patient 'treadmill' for missed calls. Modern healthcare. 2015;45(3):18-20. https://psnet.ahrq.gov/issue/time-tackle-diagnostic-errors-physicians-blame-pa…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841786/psn-pdf
    December 21, 2022 - National Patient Safety Board Act of 2022. December 21, 2022 HR 9377, 117th Cong, 2d Sess (2022). https://psnet.ahrq.gov/issue/national-patient-safety-board-act-2022 The need for a national government-led patient safety effort has long been advocated for. This legislation outlines the structure of a federal agency…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48027/psn-pdf
    June 05, 2019 - Dangers of diagnostic overshadowing. June 5, 2019 Iezzoni LI. Dangers of Diagnostic Overshadowing. N Engl J Med. 2019;380(22):2092-2093. doi:10.1056/NEJMp1903078. https://psnet.ahrq.gov/issue/dangers-diagnostic-overshadowing This commentary describes an incident involving diagnostic error and substandard care of a…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41159/psn-pdf
    September 29, 2017 - A nurse-led approach to developing and implementing a collaborative count policy. September 29, 2017 Norton EK, Micheli AJ, Gedney J, et al. A nurse-led approach to developing and implementing a collaborative count policy. AORN J. 2012;95(2):222-7. doi:10.1016/j.aorn.2011.11.009. https://psnet.ahrq.gov/issue/nurse…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37138/psn-pdf
    October 04, 2011 - Drug administration errors in an institution for individuals with intellectual disability: an observational study. October 4, 2011 van den Bemt PMLA, Robertz R, de Jong AL, et al. Drug administration errors in an institution for individuals with intellectual disability: an observational study. J Intellect Disabil R…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50663/psn-pdf
    November 13, 2019 - Investigation into Electronic Prescribing and Medicines Administration Systems and Safe Discharge. November 13, 2019 Farnborough, UK: Healthcare Safety Investigation Branch; October 2019. https://psnet.ahrq.gov/issue/investigation-electronic-prescribing-and-medicines-administration-systems- and-safe-discharge Des…
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