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Showing results for "incidents".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39621/psn-pdf
    June 23, 2010 - Defining near misses: towards a sharpened definition based on empirical data about error handling processes. June 23, 2010 Kessels-Habraken M, Van der Schaaf T, De Jonge J, et al. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med. 2010;70(9):130…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44181/psn-pdf
    June 03, 2015 - Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013. June 3, 2015 Krein SL, Fowler KE, Ratz D, et al. Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013. BMJ Qual Saf. 2015;24(6):385-92. doi:10.1136/bmjqs-2014-003870. https://psnet.ah…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47538/psn-pdf
    January 23, 2019 - What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. January 23, 2019 Keers RN, Plácido M, Bennett K, et al. What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLoS One. 2018;13(10):e0206233. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50708/psn-pdf
    December 04, 2019 - Identifying medication errors in neonatal intensive care units: a two-center study December 4, 2019 Eslami K, Aletayeb F, Aletayeb SMH, et al. Identifying medication errors in neonatal intensive care units: a two-center study. BMC Pediatr. 2019;19(1):365. doi:10.1186/s12887-019-1748-4. https://psnet.ahrq.gov/issue…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837983/psn-pdf
    August 31, 2022 - Identifying and Understanding Ways to Address the Impact of Racism on Patient Safety in Health Care Settings. August 31, 2022 Schulson LB, Thomas AD, Tsuei J, et al.  Santa Monica, CA: RAND Corporation; 2022 https://psnet.ahrq.gov/issue/identifying-and-understanding-ways-address-impact-racism-patient-safety- …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41305/psn-pdf
    April 18, 2012 - Is computer-assisted telephone triage safe? A prospective surveillance study in walk-in patients with non-life-threatening medical conditions. April 18, 2012 Meer A, Gwerder T, Duembgen L, et al. Is computer-assisted telephone triage safe? A prospective surveillance study in walk-in patients with non-life-threaten…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43981/psn-pdf
    April 22, 2015 - National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ?85% of patient deaths. April 22, 2015 Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac sur…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73373/psn-pdf
    January 01, 2022 - State medical board regulation of compounding in physician offices. June 9, 2021 Reynolds KA, Hellquist K, Ibrahim SA, et al. State medical board regulation of compounding in physician offices. Arch Dermatol Res. 2022;314(4):363-367. doi:10.1007/s00403-021-02237-8. https://psnet.ahrq.gov/issue/state-medical-board-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838088/psn-pdf
    September 14, 2022 - 'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death. September 14, 2022 Mills M. The Guardian. September 3, 2022. https://psnet.ahrq.gov/issue/we-had-such-trust-we-feel-such-fools-how-shocking-hospital-mistakes-led-our- daughters-death Families experiencing medical …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48011/psn-pdf
    May 29, 2019 - Is it time for safeguards in the adoption of robotic surgery? May 29, 2019 Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic Surgery? JAMA. 2019;321(20):1971-1972. doi:10.1001/jama.2019.3736. https://psnet.ahrq.gov/issue/it-time-safeguards-adoption-robotic-surgery The FDA recently raised …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43810/psn-pdf
    March 15, 2016 - Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned from the field. March 15, 2016 Chen Q, Shin MH, Chan J, et al. Partnering With VA Stakeholders to Develop a Comprehensive Patient Safety Data Display: Lessons Learned From the Field. Am J Med Qual. 2016;31(2):17…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849331/psn-pdf
    May 24, 2023 - Long-term care healthcare-associated infections in 2022: an analysis of 20,216 reports. May 24, 2023 Kepner S, Bingman C, Jones RM. Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports. Patient Saf. 2023;5(2):20-31. doi:10.33940/001c.74494. https://psnet.ahrq.gov/issue/long-term-…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50916/psn-pdf
    February 19, 2020 - Patient safety and suicide prevention in mental health services: time for a new paradigm? February 19, 2020 Quinlivan L, Littlewood DL, Webb RT, et al. Patient safety and suicide prevention in mental health services: time for a new paradigm? J Mental Health. 2020;29(1):1-5. doi:10.1080/09638237.2020.1714013. https…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48059/psn-pdf
    June 05, 2019 - Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. June 5, 2019 Macrae C. Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. J R Soc Med. 2019;112(9):365-369. doi:10.1177/014107…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46079/psn-pdf
    June 28, 2017 - Death due to pharmacy compounding error reinforces need for safety focus. June 28, 2017 ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4. https://psnet.ahrq.gov/issue/death-due-pharmacy-compounding-error-reinforces-need-safety-focus Compounding pharmacies prepare medicines for patients that a…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837893/psn-pdf
    August 24, 2022 - Exploring nurses' attitudes, skills, and beliefs of medication safety practices. August 24, 2022 Arkin L, Schuermann A, Penoyer D, et al. Exploring nurses' attitudes, skills, and beliefs of medication safety practices. J Nurs Care Qual. 2022;37(4):319-326. doi:10.1097/ncq.0000000000000635. https://psnet.ahrq.gov/i…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839322/psn-pdf
    November 02, 2022 - A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. November 2, 2022 Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. JCO Oncol Pract. 2022;18(12):833-839. doi:10.…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39600/psn-pdf
    June 16, 2010 - Developing a patient safety surveillance system to identify adverse events in the intensive care unit. June 16, 2010 Stockwell DC, Kane-Gill SL. Developing a patient safety surveillance system to identify adverse events in the intensive care unit. Crit Care Med. 2010;38(6 Suppl):S117-25. doi:10.1097/CCM.0b013e3181d…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45935/psn-pdf
    September 29, 2017 - Radiology research in quality and safety: current trends and future needs. September 29, 2017 Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021. https://psnet.ahrq.gov/issue/radiolog…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837894/psn-pdf
    August 24, 2022 - Identifying boundary spanning reporter roles in patient safety events. August 24, 2022 Hurley VB, Boxley C, Sloss EA, et al. Identifying boundary spanning reporter roles in patient safety events. J Patient Saf Risk Manag. 2022;27(4):181-187. doi:10.1177/25160435221103096. https://psnet.ahrq.gov/issue/identifying-b…
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