Results

Total Results: over 10,000 records

Showing results for "incidents".

9001. Finding blunders in thyroid testing: experience in newborns. | PSNet
      psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
      March 04, 2020 - Study Finding blunders in thyroid testing: experience in newborns. Citation Text: Zilka LJ, Lott JA, Baker LC, et al. Finding blunders in thyroid testing: experience in newborns. J Clin Lab Anal. 2008;22(4):254-6. doi:10.1002/jcla.20247. Copy Citation Format: DOI Google S…

9002. Quality improvement and safety in pediatric emergency medicine. | PSNet
      psnet.ahrq.gov/issue/quality-improvement-and-safety-pediatric-emergency-medicine
      March 12, 2025 - Review Quality improvement and safety in pediatric emergency medicine. Citation Text: Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010. Copy Citation Format: …

9003. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. | PSNet
      psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention
      November 16, 2022 - Study Wrong-site craniotomy: analysis of 35 cases and systems for prevention. Citation Text: Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282. Copy Citation …

9004. Wrong site surgery near misses and actual occurrences. | PSNet
      psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences
      November 30, 2012 - Study Wrong site surgery near misses and actual occurrences. Citation Text: 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. Copy Citation Format: DOI Google Scholar …

9005. Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. | PSNet
      psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
      September 07, 2016 - Book/Report Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Citation Text: Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023.  Publication GAO-23-1…

9006. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. | PSNet
      psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia
      February 03, 2021 - Commentary Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Citation Text: Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.000…

9007. A statewide voluntary patient safety initiative: the Georgia experience. | PSNet
      psnet.ahrq.gov/issue/statewide-voluntary-patient-safety-initiative-georgia-experience
      October 04, 2011 - Commentary A statewide voluntary patient safety initiative: the Georgia experience. Citation Text: Rask KJ, Schuessler LD, Naylor DV. A statewide voluntary patient safety initiative: the Georgia experiene. Jt Comm J Qual Patient Saf. 2006;32(10):564-72. Copy Citation Format: …

9008. Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. | PSNet
      psnet.ahrq.gov/issue/influence-house-staff-experience-teaching-hospital-mortality-july-phenomenon-revisited
      March 04, 2015 - Study Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited. Citation Text: van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7…

9009. Measurement of ambulatory medication errors in children: a scoping review. | PSNet
      psnet.ahrq.gov/issue/measurement-ambulatory-medication-errors-children-scoping-review
      February 07, 2024 - Review Measurement of ambulatory medication errors in children: a scoping review. Citation Text: Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. Copy Citat…

9010. Costs and consequences associated with misdiagnosed lower extremity cellulitis. | PSNet
      psnet.ahrq.gov/issue/costs-and-consequences-associated-misdiagnosed-lower-extremity-cellulitis
      November 12, 2014 - Study Costs and consequences associated with misdiagnosed lower extremity cellulitis. Citation Text: Weng QY, Raff AB, Cohen JM, et al. Costs and Consequences Associated With Misdiagnosed Lower Extremity Cellulitis. JAMA Dermatol. 2016;153(2). doi:10.1001/jamadermatol.2016.3816. Copy C…

9011. Managing clinical failure: a complex adaptive system perspective. | PSNet
      psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
      August 13, 2014 - Study Managing clinical failure: a complex adaptive system perspective. Citation Text: Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336. Copy Citation Format: …

9012. Bringing the equity lens to patient safety event reporting. | PSNet
      psnet.ahrq.gov/issue/bringing-equity-lens-patient-safety-event-reporting
      September 21, 2009 - Commentary Bringing the equity lens to patient safety event reporting. Citation Text: Gandhi TK, Schulson LB, Thomas AD. Bringing the equity lens to patient safety event reporting. Jt Comm J Qual Patient Saf. 2024;50(1):87-89. doi:10.1016/j.jcjq.2023.09.003. Copy Citation Format: …

9013. Improving diagnosis: adding context to cognition. | PSNet
      psnet.ahrq.gov/issue/improving-diagnosis-adding-context-cognition
      July 12, 2023 - Commentary Improving diagnosis: adding context to cognition. Citation Text: Linzer M, Sullivan EE, Olson APJ, et al. Improving diagnosis: adding context to cognition. Diagnosis (Berl). 2023;10(1):4-8. doi:10.1515/dx-2022-0058. Copy Citation Format: DOI Google Scholar BibTeX…

9014. Reporting of hazards and near-misses in the ambulatory care setting. | PSNet
      psnet.ahrq.gov/issue/reporting-hazards-and-near-misses-ambulatory-care-setting
      October 19, 2011 - Study Reporting of hazards and near-misses in the ambulatory care setting. Citation Text: Schnall R, Bakken S. Reporting of hazards and near-misses in the ambulatory care setting. J Nurs Care Qual. 2011;26(4):328-334. doi:10.1097/NCQ.0b013e3182109204. Copy Citation Format: …

9015. Ferranti, Jeffrey | Digital Healthcare Research
      digital.ahrq.gov/principal-investigator/ferranti-jeffrey
      January 01, 2023 - Ferranti, Jeffrey Sharing adverse drug event data using business intelligence technology. Citation Horvath MM, Cozart H, Ahmad A, et al. Sharing adverse drug event data using business intelligence technology. J Patient Saf 2009 Mar;5(1):35-41. Principal Investigator …

9016. Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. | PSNet
      psnet.ahrq.gov/issue/economics-medication-safety-improving-medication-safety-through-collective-real-time-learning
      October 07, 2020 - Book/Report Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. Citation Text: Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning. de Bienassis K, Esmail L, Lopert R, Klazinga N for the O…

9017. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department. | PSNet
      psnet.ahrq.gov/issue/distributed-cognition-and-role-nurses-diagnostic-safety-emergency-department
      April 13, 2011 - Book/Report Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department. Citation Text: Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department. Manojlovich M, Krein SL, Kronick SL, et al. Rockville, MD: Agency for H…

9018. Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory Care. | PSNet
      psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announcements-understand-and-improve-diagnostic
      August 15, 2018 - Press Release/Announcement Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory Care. Citation Text: Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory …

9019. Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. | PSNet
      psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research
      May 25, 2022 - Commentary Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. Citation Text: Armstrong N. Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. BMJ Qual Saf. 2018;27(7):571-575. doi:10.1136/b…

9020. Infection prevention in the operating room anesthesia work area. | PSNet
      psnet.ahrq.gov/issue/infection-prevention-operating-room-anesthesia-work-area
      March 02, 2014 - Commentary Infection prevention in the operating room anesthesia work area. Citation Text: Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303. Copy Citation …