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Showing results for "incidents".

  1. The morbidity and mortality conference in PICUs in the United States: a national survey. | PSNet

    psnet.ahrq.gov/issue/morbidity-and-mortality-conference-picus-united-states-national-survey
    October 20, 2014 - Study The morbidity and mortality conference in PICUs in the United States: a national survey. Citation Text: Cifra CL, Bembea MM, Fackler JC, et al. The morbidity and mortality conference in PICUs in the United States: a national survey. Crit Care Med. 2014;42(10):2252-7. doi:10.1097/CC…

  2. The emergency department trigger tool: a novel approach to screening for quality and safety events. | PSNet

    psnet.ahrq.gov/issue/emergency-department-trigger-tool-novel-approach-screening-quality-and-safety-events
    August 24, 2022 - Study The emergency department trigger tool: a novel approach to screening for quality and safety events. Citation Text: Griffey RT, Schneider RM, Todorov AA. The emergency department trigger tool: a novel approach to screening for quality and safety events. Ann Emerg Med. 2020;76(2):230…

  3. Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults. | PSNet

    psnet.ahrq.gov/issue/underdiagnosis-dementia-observational-study-patterns-diagnosis-and-awareness-us-older-adults
    October 14, 2016 - Study Classic Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults. Citation Text: Amjad H, Roth DL, Sheehan OC, et al. Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awaren…

  4. A combined assessment tool of teamwork, communication, and workload in hospital procedural units. | PSNet

    psnet.ahrq.gov/issue/combined-assessment-tool-teamwork-communication-and-workload-hospital-procedural-units
    August 04, 2021 - Study A combined assessment tool of teamwork, communication, and workload in hospital procedural units. Citation Text: Weaver BW, Murphy DJ. A combined assessment tool of teamwork, communication, and workload in hospital procedural units. Jt Comm J Qual Patient Saf. 2024;50(3):219-227. d…

  5. Maternal mortality: near-miss events in middle-income countries, a systematic review. | PSNet

    psnet.ahrq.gov/issue/maternal-mortality-near-miss-events-middle-income-countries-systematic-review
    October 13, 2021 - Review Maternal mortality: near-miss events in middle-income countries, a systematic review. Citation Text: Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Maternal mortality: near-miss events in middle-income countries, a systematic review. Bull World Health Organ. 2021;99(10):693-70…

  6. Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis. | PSNet

    psnet.ahrq.gov/issue/preventable-anesthesia-related-adverse-events-large-tertiary-care-center-nine-year
    November 12, 2014 - Study Preventable anesthesia-related adverse events at a large tertiary care center: a nine-year retrospective analysis. Citation Text: Curatolo CJ, McCormick PJ, Hyman JB, et al. Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Ana…

  7. Discrepancies between home medications listed at hospital admission and reported medical conditions. | PSNet

    psnet.ahrq.gov/issue/discrepancies-between-home-medications-listed-hospital-admission-and-reported-medical
    November 03, 2021 - Study Discrepancies between home medications listed at hospital admission and reported medical conditions. Citation Text: Slain D, Kincaid SE, Dunsworth TS. Discrepancies between home medications listed at hospital admission and reported medical conditions. Am J Geriatr Pharmacother.…

  8. Chemotherapy errors: a call for a standardized approach to measurement and reporting. | PSNet

    psnet.ahrq.gov/issue/chemotherapy-errors-call-standardized-approach-measurement-and-reporting
    October 28, 2020 - Commentary Chemotherapy errors: a call for a standardized approach to measurement and reporting. Citation Text: Lennes IT, Bohlen N, Park ER, et al. Chemotherapy Errors: A Call for a Standardized Approach to Measurement and Reporting. J Oncol Pract. 2016;12(4):e495-501. doi:10.1200/JOP.2…

  9. Distractions in the operating room: a survey of the healthcare team. | PSNet

    psnet.ahrq.gov/issue/distractions-operating-room-survey-healthcare-team
    November 16, 2022 - Study Distractions in the operating room: a survey of the healthcare team. Citation Text: Nasri B-N, Mitchell JD, Jackson C, et al. Distractions in the operating room: a survey of the healthcare team. Surg Endosc. 2023;37(3):2316-2325. doi:10.1007/s00464-022-09553-8. Copy Citation …

  10. VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. | PSNet

    psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-adverse-events
    November 22, 2017 - Book/Report VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. Citation Text: VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events. Washington, DC: United States Government Accountability Office; July 29, 2015…

  11. Impact of a daily huddle on safety in perioperative services. | PSNet

    psnet.ahrq.gov/issue/impact-daily-huddle-safety-perioperative-services
    March 03, 2021 - Study Impact of a daily huddle on safety in perioperative services. Citation Text: Tuyishime H, Claure RE, Balakrishnan K, et al. Impact of a daily huddle on safety in perioperative services. Jt Comm J Qual Patient Saf. 2024;50(9):678-683. doi:10.1016/j.jcjq.2024.04.012. Copy Citation …

  12. Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study. | PSNet

    psnet.ahrq.gov/issue/patients-perceptions-importance-self-administered-correct-site-surgery-checklist-multisite
    May 25, 2022 - Study Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study. Citation Text: Krenzischek DA, Card E, Mamaril M, et al. Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study. J Peria…

  13. Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities. | PSNet

    psnet.ahrq.gov/issue/data-driven-quality-improvement-culture-change-and-high-reliability-journey-special-hospital
    March 24, 2021 - Commentary Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities. Citation Text: Barba V, Foreman K, Robey K. Data-driven quality improvement, culture change, and the high relia…

  14. The economic burden of nurse-sensitive adverse events in 22 medical-surgical units: retrospective and matching analysis. | PSNet

    psnet.ahrq.gov/issue/economic-burden-nurse-sensitive-adverse-events-22-medical-surgical-units-retrospective-and
    December 15, 2021 - Study The economic burden of nurse-sensitive adverse events in 22 medical-surgical units: retrospective and matching analysis. Citation Text: Tchouaket E, Dubois C-A, D'Amour D. The economic burden of nurse-sensitive adverse events in 22 medical-surgical units: retrospective and matching…

  15. Do leadership style, unit climate, and safety climate contribute to safe medication practices? | PSNet

    psnet.ahrq.gov/issue/do-leadership-style-unit-climate-and-safety-climate-contribute-safe-medication-practices
    May 13, 2020 - Study Do leadership style, unit climate, and safety climate contribute to safe medication practices? Citation Text: Farag A, Tullai-McGuinness S, Anthony MK, et al. Do Leadership Style, Unit Climate, and Safety Climate Contribute to Safe Medication Practices? J Nurs Adm. 2017;47(1):8-15.…

  16. Five topics health care simulation can address to improve patient safety: results from a consensus process. | PSNet

    psnet.ahrq.gov/issue/five-topics-health-care-simulation-can-address-improve-patient-safety-results-consensus
    June 28, 2023 - Study Five topics health care simulation can address to improve patient safety: results from a consensus process. Citation Text: Sollid SJM, Dieckman P, Aase K, et al. Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process. J Patient Sa…

  17. The Child Health PSO at 10 years: an emerging learning network. | PSNet

    psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-learning-network
    July 28, 2021 - Commentary The Child Health PSO at 10 years: an emerging learning network. Citation Text: 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. Copy Citation Format: …

  18. Vulnerability of the medical product supply chain: the wake-up call of COVID-19. | PSNet

    psnet.ahrq.gov/issue/vulnerability-medical-product-supply-chain-wake-call-covid-19
    December 02, 2020 - Commentary Emerging Classic Vulnerability of the medical product supply chain: the wake-up call of COVID-19. Citation Text: Miller FA, Young SB, Dobrow M, et al. Vulnerability of the medical product supply chain: the wake-up call of COVID-19. BMJ Qual Saf. 2020;…

  19. Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/surgeon-burnout-impact-patient-safety-and-professionalism-systematic-review-and-meta-analysis
    October 14, 2020 - Review Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis. Citation Text: Al-Ghunaim TA, Johnson J, Biyani CS, et al. Surgeon burnout, impact on patient safety and professionalism: A systematic review and meta-analysis. Am J Surg. 2022;22…

  20. Implementation of safeguards to improve patient safety in chemotherapy. | PSNet

    psnet.ahrq.gov/issue/implementation-safeguards-improve-patient-safety-chemotherapy
    September 19, 2012 - Study Implementation of safeguards to improve patient safety in chemotherapy. Citation Text: Huertas-Fernández MJ, Martínez-Bautista Mª J, Rodríguez-Mateos ME, et al. Implementation of safeguards to improve patient safety in chemotherapy. Clin Transl Oncol. 2017;19(9):1099-1106. doi:10.1…
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