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Showing results for "involved".

61. Understanding complexity in a safety critical setting: a systems approach to medication administration. | PSNet
    psnet.ahrq.gov/issue/understanding-complexity-safety-critical-setting-systems-approach-medication-administration
    February 01, 2023 - The authors discuss the networks involved in medication administration (e.g., task network, social network … , information network) and how the complexities involved in each network contribute to medication administration

62. In response to “Getting to the Root of the Matter” (June 2005) | PSNet
    psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
    June 01, 2005 - While they do mention conducting "interviews with key staff involved in the error," they do not propose … My interpretation is that this includes those directly involved in the error. … Williams suggests that individuals directly involved in an error should participate in the root cause … The viewpoint of the health care provider involved in an error, however, is critical. … Finally, when changes are finalized, we describe them to both the involved units and the individual involved

63. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
    psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
    June 24, 2020 - Upon discovery of the error, the nurse involved was fired by the hospital and her license was revoked … error or at-risk/reckless behavior is a very difficult judgment, and the outcome depends more on who is involved … Second, determine the (clinical) knowledge of the person involved: did he or she have sufficient training … What does the person involved believe should be done? … organization's risk, but it is probably seen as very unjust by all other major stakeholders: the nurse involved

64. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36744/psn-pdf
    August 02, 2011 - Nurses relate the contributing factors involved in medication errors. … Nurses relate the contributing factors involved in medication errors. … https://psnet.ahrq.gov/issue/nurses-relate-contributing-factors-involved-medication-errors The investigators … https://psnet.ahrq.gov/issue/nurses-relate-contributing-factors-involved-medication-errors

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867441/psn-pdf
    January 08, 2025 - Consumers were involved in the planning and engagement stages of most studies, but less frequently involved … The authors recommend increased reporting of how consumers were involved, the types of consumers, and

66. Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants. | PSNet
    psnet.ahrq.gov/issue/multicomponent-pharmacist-intervention-did-not-reduce-clinically-important-medication-errors
    March 17, 2021 - Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct … View More Related Resources Ambulatory medication errors and adverse events involved

67. Parent participation in morbidity and mortality review: parent and physician perspectives. | PSNet
    psnet.ahrq.gov/issue/parent-participation-morbidity-and-mortality-review-parent-and-physician-perspectives
    May 18, 2022 - Parents have reported the importance of being involved in discussions with clinicians following adverse … Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent

68. Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults. | PSNet
    psnet.ahrq.gov/issue/assessment-patient-preferred-language-achieve-goal-aligned-deprescribing-older-adults
    December 19, 2018 - The most preferred phrase involved an explanation of risk of side effects associated with the medications … while the least preferred options focused on the effort involved in taking the medication and “this

69. Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents. | PSNet
    psnet.ahrq.gov/issue/prosocial-voice-hierarchy-healthcare-professionals-role-emotions-after-harmful-patient-safety
    February 23, 2022 - Healthcare professionals who are involved in patient safety incidents can experience psychological … urology, and maternity care, this study explored the emotional experience of healthcare professionals involved

70. How safety is compromised when hospital equipment is a poor fit for patients who are obese. | PSNet
    psnet.ahrq.gov/issue/how-safety-compromised-when-hospital-equipment-poor-fit-patients-who-are-obese
    October 07, 2020 - From 2009-2018, 107 events were identified; nearly half of events involved MRI or CT scanners and one-quarter … involved stretchers.

71. Living with the aftermath: the second victim experience among certified registered nurse anesthetists. | PSNet
    psnet.ahrq.gov/issue/living-aftermath-second-victim-experience-among-certified-registered-nurse-anesthetists
    April 12, 2019 - Many healthcare staff who are involved in an adverse event may experience negative physical and psychological … April 3, 2024 Peer support and second victim programs for anesthesia professionals involved

72. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. | PSNet
    psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
    May 13, 2020 - harm, this book explores the ethics that drive decision making and management of the professionals involved … The authors believe that the more players involved with the decision-making process, the more opportunities

73. In Conversation With… Rebecca Lawton, PhD | PSNet
    psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - Patients can also be involved in setting priorities. … There are also ways that patients can get involved in maintaining their own personal safety. … Currently, we're involved in work where patients are encouraged to be more involved in their diagnostic … The problem is that some people just don't want to be involved. … Some people are not able to be involved.

74. Unsafe care in residential settings for older adults. A content analysis of accreditation reports. | PSNet
    psnet.ahrq.gov/issue/unsafe-care-residential-settings-older-adults-content-analysis-accreditation-reports
    August 16, 2023 - Nearly 50% of incidents involved clinical processes or procedures, and 25% involved documentation errors

75. Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. | PSNet
    psnet.ahrq.gov/issue/cognitive-errors-and-logistical-breakdowns-contributing-missed-and-delayed-diagnoses-breast
    March 02, 2011 - This study analyzed 56 missed or delayed cancer diagnoses and found that virtually all cases involved … cognitive errors and half involved logistical breakdowns .

76. Emergency hospitalizations for unsupervised prescription medication ingestions by young children. | PSNet
    psnet.ahrq.gov/issue/emergency-hospitalizations-unsupervised-prescription-medication-ingestions-young-children
    April 22, 2020 - Three-quarters of these events involved 1- or 2-year-old children. … Download Citation Related Resources From the Same Author(s) Circumstances involved

77. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46772/psn-pdf
    March 04, 2019 - case-second-victim-support-program-pediatrics-successes-and-challenges- implementation After being involved … psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event … https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854819/psn-pdf
    October 25, 2023 - second-victim-syndrome-intensive-care-unit-healthcare-workers-systematic- review-and-meta Healthcare workers who are involved … recover at all, underscoring the importance of organizational support programs for healthcare workers involved … second-victim-phenomenon-harsh-reality-health-care-professions https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events

79. Medication-related Malpractice Risks. 2016 CRICO Strategies National CBS Report. | PSNet
    psnet.ahrq.gov/issue/medication-related-malpractice-risks-2016-crico-strategies-national-cbs-report
    July 18, 2018 - The majority of medication safety incidents involved primary care providers or hospital-based nurses … , and drugs commonly involved included analgesics, anticoagulants, and antibiotics.

80. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45969/psn-pdf
    January 07, 2019 - surgeon-second-victim-results-boston-intraoperative-adverse-events-surgeons-attitude-bisa https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event … https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event