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Showing results for "incidents".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47696/psn-pdf
    February 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41222/psn-pdf
    May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization (PSO). May 1, 2016 Agency for Healthcare Quality and Research. https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization- pso Patient safety organizations (PSO) present a unique o…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44966/psn-pdf
    March 16, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance. March 16, 2016 McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF. https://psnet.ahrq.gov/issue/confidential-physician-feedback-rep…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38892/psn-pdf
    August 26, 2009 - Wrong site surgery near misses and actual occurrences. August 26, 2009 Blanco M, Clarke JR, Martindell D. Wrong site surgery near misses and actual occurrences. AORN J. 2009;90(2):215-8, 221-2. doi:10.1016/j.aorn.2009.07.010. https://psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences This a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39829/psn-pdf
    January 09, 2025 - Hospital Reporting Program: Annual Summary. January 9, 2025 Portland, OR: Oregon Patient Safety Commission. https://psnet.ahrq.gov/issue/hospital-reporting-program-annual-summary This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73898/psn-pdf
    September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.  September 29, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021. https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations In-depth failure investigations provide improvement insights for individuals and or…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42481/psn-pdf
    August 14, 2013 - Drug administration errors in hospital inpatients: a systematic review. August 14, 2013 Berdot S, Gillaizeau F, Caruba T, et al. Drug administration errors in hospital inpatients: a systematic review. PLoS One. 2013;8(6):e68856. doi:10.1371/journal.pone.0068856. https://psnet.ahrq.gov/issue/drug-administration-err…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41926/psn-pdf
    January 02, 2013 - As she lay dying: how I fought to stop medical errors from killing my mom. January 2, 2013 Welch JR. As she lay dying: how I fought to stop medical errors from killing my mom. Health Aff (Millwood). 2012;31(12):2817-2820. doi:10.1377/hlthaff.2012.0833. https://psnet.ahrq.gov/issue/she-lay-dying-how-i-fought-stop-m…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38418/psn-pdf
    February 18, 2009 - Using snowball sampling method with nurses to understand medication administration errors. February 18, 2009 Sheu S-J, Wei I-L, Chen C-H, et al. Using snowball sampling method with nurses to understand medication administration errors. J Clin Nurs. 2009;18(4):559-69. doi:10.1111/j.1365-2702.2007.02048.x. https://p…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35500/psn-pdf
    February 22, 2010 - Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program. February 22, 2010 Weinstock PH, Kappus LJ, Kleinman ME, et al. Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program. Pediatr Crit Care Med. 2005;6(6):6…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40307/psn-pdf
    April 20, 2011 - The interrelationship of isolation precautions and adverse events in an acute care facility. April 20, 2011 Spence MR, McQuaid M. The interrelationship of isolation precautions and adverse events in an acute care facility. Am J Infect Control. 2011;39(2):154-155. doi:10.1016/j.ajic.2010.04.213. https://psnet.ahrq.…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46052/psn-pdf
    December 19, 2017 - Correlates of the third victim phenomenon. December 19, 2017 Russ MJ. Correlates of the Third Victim Phenomenon. Psychiatr Q. 2017;88(4):917-920. doi:10.1007/s11126-017-9511-1. https://psnet.ahrq.gov/issue/correlates-third-victim-phenomenon A sentinel event affects patients, their families, clinicians involved, an…
  13. www.ahrq.gov/research/shuttered/acfselection/appendixc.html
    July 01, 2018 - Disaster Alternate Care Facilities: Report and Interactive Tools Appendix C: Alternate Care Facility Questionnaire Previous Page Next Page Table of Contents Disaster Alternate Care Facilities: Report and Interactive Tools Executive Summary Chapter 1. Objectives Chapter 2. Background Chapter …
  14. www.ahrq.gov/sites/default/files/2024-09/secola-report.pdf
    January 01, 2024 - Final Progress Report: Central Venous Catheter (CVC)–Related Bloodstream Infections in Pediatric Cancer 1 Central Venous Catheter (CVC)–Related Bloodstream Infections in Pediatric Cancer Principal Investigator: Rita Secola, RN, PhD, CPON Organization: University of California Los Angeles, NIHAward@research.ucla.e…
  15. www.ahrq.gov/hai/pfp/haccost2017.html
    November 01, 2017 - Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions Next Page Table of Contents Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions Discussion Results References …
  16. www.uspreventiveservicestaskforce.org/home/getfilebytoken/MLeu_yFpPwzcZwKG6fw5ZY
    April 26, 2022 - Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Modeling Study for the USPSTF Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer Updated Modeling Study for the US Preventive Services Task Force Steven P. Dehmer, PhD; Lauren R. O’Keefe, MS; Corinne V. Evans, MPP; Janelle M…
  17. www.uspreventiveservicestaskforce.org/uspstf/recommendation/healthy-diet-promotion-behavioral-counseling-1996
    January 01, 1996 - Share to Facebook Share to X Share to WhatsApp Share to Email Print archived Final Recommendation Statement Healthy Diet Promotion: Behavioral Counseling, 1996 January 01, 1996 Recommendations made by the USPSTF are independent of the U…
  18. Layout 1 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/prostate-cancer_executive.pdf
    February 01, 2008 - Layout 1 Background and Key Questions Prostate cancer is the most common nondermatologic cancer in men. In 2007 an estimated 218,890 men were diagnosed with, and 27,050 deaths were attributed to, prostate cancer in the United States. Approximately 90 percent of men with prostate cancer have disease considered confine…
  19. effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/pbi-protocol.pdf
    August 09, 2021 - Partial Breast Irradiation for Breast Cancer: Systematic Review Protocol Evidence-based Practice Center Systematic Review Protocol Project Title: Partial Breast Irradiation for Breast Cancer I. Background and Objectives for the Systematic Review With an estimated 2.3 million new cases in 2020, breast canc…
  20. www.uspreventiveservicestaskforce.org/home/getfilebytoken/Xbtq4oDQwVo7KgmSjnnDbz
    November 01, 2021 - Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the USPSTF Copyright 2016 American Medical Association. All rights reserved. Screening for Colorectal Cancer Updated Evidence Report and Systematic Review for the US Preventive Services Task Force Jennifer S. Lin, MD; Margaret A. Pipe…