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Showing results for "incidents".

6621. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35019/psn-pdf
      June 22, 2009 - Improving patient safety in critical care: big challenge, exciting opportunity/L'amelioration de la securite des patients a l'unite des soins intensifs : un grand defi, une occasion stimulante. June 22, 2009 Dodek P. Improving patient safety in critical care: big challenge, exciting opportunity. Can J Anaesth. 20…

6622. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46444/psn-pdf
      December 19, 2017 - Nil per os orders for imaging: a teachable moment. December 19, 2017 Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943. https://psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment Patients are…

6623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37398/psn-pdf
      March 28, 2012 - A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. March 28, 2012 Oken A, Rasmussen MD, Slagle JM, et al. A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting. Anesth…

6624. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866164/psn-pdf
      June 19, 2024 - What is the effectiveness of reporting systems in promoting learning in healthcare? June 19, 2024 Sehgal A. What is the effectiveness of reporting systems in promoting learning in healthcare? Br J Hosp Med (Lond). 2024;85(4):1-9. doi:10.12968/hmed.2023.0444. https://psnet.ahrq.gov/issue/what-effectiveness-reportin…

6625. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36838/psn-pdf
      April 19, 2011 - A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. April 19, 2011 Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Qual Health Care. 2001;10(4):250-6. https://psn…

6626. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73536/psn-pdf
      July 28, 2021 - Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study. July 28, 2021 doi:http://doi.org/10.1136/bmjopen-2020-048316. https://psnet.ahrq.gov/issue/epidemiology-healthcare-harm-new-zealand-general-practice-retrospective- records-review-study In this retrospective stud…

6627. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849138/psn-pdf
      May 17, 2023 - Non-accidental Injuries in Infants Attending the Emergency Department. May 17, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; April 2023. https://psnet.ahrq.gov/issue/non-accidental-injuries-infants-attending-emergency-department Misattribution of child maltreatment injuries can be a serious misdiag…

6628. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46963/psn-pdf
      April 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris…

6629. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47128/psn-pdf
      October 13, 2018 - Matt's story: learning from heartbreak. October 13, 2018 Miller K, Dastoli A. Matt's story: learning from heartbreak. Int J Qual Health Care. 2018;30(8):654-657. doi:10.1093/intqhc/mzy076. https://psnet.ahrq.gov/issue/matts-story-learning-heartbreak Medical error affects the lives of patients, families, and member…

6630. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46519/psn-pdf
      December 22, 2018 - Delirium in hospitalized older adults. December 22, 2018 Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-1466. doi:10.1056/NEJMcp1605501. https://psnet.ahrq.gov/issue/delirium-hospitalized-older-adults Delirium is considered a patient safety problem that can be prevented with…

6631. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44111/psn-pdf
      October 21, 2015 - Analysis of medication prescribing errors in critically ill children. October 21, 2015 Glanzmann C, Frey B, Meier CR, et al. Analysis of medication prescribing errors in critically ill children. Eur J Pediatr. 2015;174(10):1347-1355. doi:10.1007/s00431-015-2542-4. https://psnet.ahrq.gov/issue/analysis-medication-p…

6632. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43066/psn-pdf
      December 10, 2014 - Reminder: pay attention to the appearance of your medicines. December 10, 2014 ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2. https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines This newsletter article describes an incident involving a patient who noticed that the tabl…

6633. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47028/psn-pdf
      May 02, 2018 - Medication errors 2018: the year in review. May 2, 2018 Valentine D, Ingram V, Fobi BNN, Brahmbhatt V. Pharmacy Practice News. April 4, 2018. https://psnet.ahrq.gov/issue/medication-errors-2018-year-review Despite considerable effort, medication errors continue to occur and result in patient harm. Summari…

6634. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60040/psn-pdf
      March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital Complaints. March 11, 2020 Newcastle upon Tyne, UK: Healthwatch; January 2020. https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints Organizations need to do more than report and collect complaint data to realize improvements based on what is…

6635. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37258/psn-pdf
      March 23, 2011 - French national survey of inpatient adverse events prospectively assessed with ward staff. March 23, 2011 Michel P, Quenon JL, Djihoud A, et al. French national survey of inpatient adverse events prospectively assessed with ward staff. Qual Saf Health Care. 2007;16(5):369-77. https://psnet.ahrq.gov/issue/french-na…

6636. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836763/psn-pdf
      March 16, 2022 - Maternity Pre-arrival Instructions by 999 Call Handlers. March 16, 2022 Farnborough, UK: Healthcare Safety Investigation Branch; February 2022. https://psnet.ahrq.gov/issue/maternity-pre-arrival-instructions-999-call-handlers Pre-hospital emergency care can be vulnerable to timing, information, and task failures th…

6637. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44000/psn-pdf
      July 18, 2016 - Elucidating reasons for resident underutilization of electronic adverse event reporting. July 18, 2016 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:10.1177/1062860615574504. https://psnet.ahrq.gov/iss…

6638. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38068/psn-pdf
      March 10, 2011 - The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. March 10, 2011 Ammenwerth E, Schnell-Inderst P, Machan C, et al. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15(5):585-600. …

6639. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73602/psn-pdf
      August 18, 2021 - The Child Health PSO at 10 years: an emerging learning network. August 18, 2021 Levy FH, Conrad KA, Kemper C, et al. The Child Health PSO at 10 Years: an emerging learning network. Pediatr Qual Saf. 2021;6(4):e449. doi:10.1097/pq9.0000000000000449. https://psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-le…

6640. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851461/psn-pdf
      July 19, 2023 - Patient safety 2.0: slaying dragons, not just investigating them. July 19, 2023 Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395. doi:10.1097/pts.0000000000001140. https://psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them …