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Showing results for "incidents".

6561. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867145/psn-pdf
      November 13, 2024 - Technology, Education and Safety. November 13, 2024 Technology, Education and Safety. Harbell MW, ed. Curr Opin Anaesthesiol. 2024;37(6):666-742. https://psnet.ahrq.gov/issue/technology-education-and-safety-3 Despite consummate efforts to improve safety, errors still occur in anesthesiology. This special collection…

6562. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36468/psn-pdf
      September 27, 2010 - Translating patient safety legislation into health care practice. September 27, 2010 Rabinowitz ABK, Clarke JR, Marella WM, et al. Translating patient safety legislation into health care practice. Jt Comm J Qual Patient Saf. 2006;32(12):676-681. https://psnet.ahrq.gov/issue/translating-patient-safety-legislation-h…

6563. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41978/psn-pdf
      January 16, 2013 - Surgical complications: disclosing adverse events and medical errors. January 16, 2013 Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008. https://psnet.ahrq.gov/issue/surgical-complications-disclosing-advers…

6564. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37155/psn-pdf
      October 06, 2011 - Classification of adverse events occurring in a surgical intensive care unit. October 6, 2011 Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care unit. Am J Surg. 2007;194(3):328-32. https://psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgi…

6565. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37533/psn-pdf
      April 22, 2011 - Systematic evaluation of errors occurring during the preparation of intravenous medication. April 22, 2011 Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ. 2008;178(1):42-8. doi:10.1503/cmaj.061743. https://psnet.ahrq.gov/issue/sys…

6566. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42546/psn-pdf
      October 02, 2013 - Detection of medication-related problems in hospital practice: a review. October 2, 2013 Manias E. Detection of medication-related problems in hospital practice: a review. Br J Clin Pharmacol. 2013;76(1):7-20. doi:10.1111/bcp.12049. https://psnet.ahrq.gov/issue/detection-medication-related-problems-hospital-practi…

6567. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42370/psn-pdf
      June 19, 2013 - Resident Projects for Improvement. June 19, 2013 Heilman J, ed. UNM CIR Journal of Quality Improvement in Healthcare. Albuquerque, NM: University of New Mexico; May 2013. https://psnet.ahrq.gov/issue/journal-quality-improvement-healthcare-second-edition This publication outlines quality and safety improvement proj…

6568. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41623/psn-pdf
      April 05, 2013 - Preventing patient harms through systems of care. April 5, 2013 Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70. doi:10.1001/jama.2012.9537. https://psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care Recent initiatives, such as the Partnership for…

6569. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43434/psn-pdf
      August 06, 2014 - Maryland hospitals aren't reporting all errors and complications, experts say. August 6, 2014 Cohn M. https://psnet.ahrq.gov/issue/maryland-hospitals-arent-reporting-all-errors-and-complications-experts-say This news article reports weaknesses in a Maryland reporting program, including poor understanding about wh…

6570. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41523/psn-pdf
      July 18, 2012 - Long-term reduction in adverse drug events: an evidence- based improvement model. July 18, 2012 Gazarian M, Graudins LV. Long-term reduction in adverse drug events: an evidence-based improvement model. Pediatrics. 2012;129(5):e1334-42. doi:10.1542/peds.2011-1902. https://psnet.ahrq.gov/issue/long-term-reduction-ad…

6571. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43225/psn-pdf
      June 04, 2014 - Addressing the taboo of medical error through IGBOs: I got burnt once! June 4, 2014 Dumitrescu A, Ryan A. Addressing the taboo of medical error through IGBOs: I got burnt once!. Eur J Pediatr. 2014;173(4):503-8. doi:10.1007/s00431-013-2168-3. https://psnet.ahrq.gov/issue/addressing-taboo-medical-error-through-igbo…

6572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35240/psn-pdf
      September 27, 2017 - Interception of potential adverse drug events in long-term psychiatric care units. September 27, 2017 Sawamura K, Ito H, Yamazumi S, et al. Interception of potential adverse drug events in long-term psychiatric care units. Psychiatry Clin Neurosci. 2005;59(4):379-84. https://psnet.ahrq.gov/issue/interception-poten…

6573. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38208/psn-pdf
      November 12, 2008 - Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. November 12, 2008 Wagar EA, Stankovic AK, Raab SS, et al. Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. Arch Pathol Lab Med. 2008;132(10):1617-22. doi:10.1043/1543- 2165(2008)132[1617:SLEAQA]2.0.CO;2. https:/…

6574. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45540/psn-pdf
      November 01, 2016 - Performing the wrong procedure. November 1, 2016 Minnier T, Phrampus P, Waddell L. Performing the Wrong Procedure. JAMA. 2016;316(11):1207-1208. doi:10.1001/jama.2016.9134. https://psnet.ahrq.gov/issue/performing-wrong-procedure Describing an incorrect procedure incident which involved placement of a dialysis cath…

6575. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47306/psn-pdf
      March 08, 2019 - Deadly Deliveries. March 8, 2019 Young A, Kelly J, Schnaars C, et al. USA Today. https://psnet.ahrq.gov/issue/deadly-deliveries Incidence of maternal harm is increasing in the United States. This news article series reports on factors that contribute to preventable maternal mortality, such as omission of recommend…

6576. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41386/psn-pdf
      May 16, 2012 - Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study. May 16, 2012 Avery T, Barber N, Ghaleb M, et al. London, UK: General Medical Council; May 2, 2012. https://psnet.ahrq.gov/issue/investigating-prevalence-and-causes-prescribing-errors-general-practice- practice-st…

6577. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836931/psn-pdf
      April 13, 2022 - Quality Special Issue. April 13, 2022 J Med Imaging Radiat Oncol. 2022;66(2):165-309. https://psnet.ahrq.gov/issue/quality-special-issue Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, inclu…

6578. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40865/psn-pdf
      September 12, 2016 - A review of current and emerging approaches to address failure-to-rescue. September 12, 2016 Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to- rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633. https://psnet.ahrq.gov/issue/review-current-…

6579. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45241/psn-pdf
      October 31, 2023 - Hospital Harm Project. October 31, 2023 Canadian Institute for Health Information, Health Excellence Canada. https://psnet.ahrq.gov/issue/hospital-harm-project Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute c…

6580. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73124/psn-pdf
      April 07, 2021 - Safety and Quality in Perioperative Anesthesia Care. April 7, 2021 Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154. https://psnet.ahrq.gov/issue/safety-and-quality-perioperative-anesthesia-care The field of anesthesiology has realized impressive improvements in safety, yet challenges still ex…