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How to develop a second victim support program: a toolkit for health care organizations. | PSNet

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April 03, 2019 - April 3, 2019 A randomized trial of a multifactorial strategy to prevent serious fall injuries … September 19, 2016 Don't abandon the "second victims" of medical errors. … September 19, 2016 Health care workers as second victims of medical errors. … September 19, 2016 Second Victim: Error, Guilt, Trauma, and Resilience. … September 19, 2016 Medical error: the second victim.

Patient safety professionals as the third victims of adverse events. | PSNet

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July 07, 2021 - This commentary provides an overview of first victims, second victims, and third victims of medical errors … View More Related Resources Toward constructive change after making a medical … July 1, 2020 A critical review: moral injury in nurses in the aftermath of a patient … January 3, 2017 Medical error: the second victim.

Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. | PSNet

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September 07, 2011 - These data, combined with prior research connecting medical school behavior to the risk of future disciplinary … May 28, 2014 Accountability sought by patients following adverse events from medical … April 22, 2011 Claiming behaviour in a no-fault system of medical injury: a descriptive … September 29, 2017 Structuring patient and family involvement in medical error event … March 13, 2013 A comprehensive overview of medical error in hospitals using incident-reporting

The proportion of clinically relevant alarms decreases as patient clinical severity decreases in intensive care units: a pilot study. | PSNet

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November 21, 2021 - June 27, 2012 Cognitive error as the most frequent contributory factor in cases of medical … injury: a study on verdict's judgment among closed claims in Japan. … March 1, 2011 Improving alarm performance in the medical intensive care unit using delays

Caring for our own: deploying a systemwide second victim rapid response team. | PSNet

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September 19, 2016 - error, or patient-related injury. … April 20, 2016 Effectiveness of patient safety training in equipping medical students … June 23, 2021 Too many abandon the "second victims" of medical errors. … September 19, 2016 Health care workers as second victims of medical errors. … September 19, 2016 Medical error: the second victim.

Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary. | PSNet

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June 15, 2011 - April 13, 2017 A National Trauma Care System: Integrating Military and Civilian Trauma … Systems to Achieve Zero Preventable Deaths After Injury. … October 6, 2011 Teaching but not learning: how medical residency programs handle errors

Learning From Mistakes. | PSNet

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March 28, 2018 - In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical … July 16, 2014 VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. | PSNet

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September 08, 2021 - , (4) use of standardized fascial closure trays, and (5) standardized intraoperative application of wound … Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … Related Resources WebM&M Cases Uterine Artery Injury

Lessons learned from a national hospital antibiotic stewardship implementation project. | PSNet

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July 20, 2022 - July 9, 2014 How patients can improve the accuracy of their medical records. … July 17, 2024 Clinical characteristics and short-term outcomes of acute kidney injury … July 21, 2010 A multidisciplinary approach to adverse drug events in pediatric trauma … patients in an adult trauma center.

Improving perceptions of patient safety through standardizing handoffs from the emergency department to the inpatient setting: a systematic review. | PSNet

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December 21, 2022 - April 5, 2013 Medication order errors at hospital admission among children with medical … review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma … July 21, 2021 High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients.

Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. | PSNet

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September 23, 2020 - Commentary Complexity bias in the prevention of iatrogenic injury: why specific harms … Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. … Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. … May 13, 2020 Assessment of nursing home reporting of major injury falls for quality measurement

Near Miss with Bedside Medications | PSNet

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February 01, 2006 - Frequency of near misses relative to medical errors Because of the lack of systematic mechanisms to … In case of injury, there may have been no attempt at recovery, or the attempts may have been unsuccessful … Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. … From the Same Author(s) Perspective Removing Insult from Injury—Disclosing … 2004 A randomized trial of a multifactorial strategy to prevent serious fall injuries

Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications. | PSNet

psnet.ahrq.gov/issue/barriers-implementation-patient-safety-systems-healthcare-institutions-leadership-and-policy

July 14, 2010 - July 3, 2014 Economic measurement of medical errors using a hospital claims database. … May 1, 2013 The impact of medical errors on ninety-day costs and outcomes: an examination … March 4, 2011 Claiming behaviour in a no-fault system of medical injury: a descriptive

Safety climate associated with adverse events in nursing homes: a national VA study. | PSNet

psnet.ahrq.gov/issue/safety-climate-associated-adverse-events-nursing-homes-national-va-study

September 08, 2021 - The survey found that supervisor commitment to safety was associated with lower rates of major injuries … catheter use, and that environmental safety was associated with lower rates of pressure ulcers, major injuries … The Topic Long-Term Care Quality and Safety Professionals Geriatrics Nurse Care Medical

Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system. | PSNet

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February 14, 2017 - This project studied the epidemiologic viability of using an injury surveillance system to track outpatient … Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … January 6, 2018 Medical large language models are vulnerable to data-poisoning attacks

Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident safety in long-term care. | PSNet

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September 01, 2021 - Commentary Utilizing quality improvement methods to prevent falls and injury from … Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident safety … Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident safety

Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet

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May 01, 2018 - The Accreditation Council for Continuing Medical Education (ACCME) defines an ineligible company as “ … hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … patients first present to the ED. 1 The presence of pulmonary edema with hypoxemia and acute kidney injury … nitroglycerin (given that nitroprusside is relatively contraindicated in the setting of acute kidney injury … treating hypertensive emergencies, choosing appropriate antihypertensives for patients with end-organ injury

Safe use of health information technology. | PSNet

psnet.ahrq.gov/issue/safe-use-health-information-technology

December 23, 2016 - of well-intended safety alerts , and problems with poor interoperability of different electronic medical … Related Resources From the Same Author(s) Preventing falls and fall-related injuries … December 1, 2019 Surgical data recording technology: a solution to address medical errors … February 8, 2017 Preventing falls and fall-related injuries in health care facilities

Improving Hand-Off Communication. | PSNet

psnet.ahrq.gov/issue/improving-hand-communication

April 24, 2007 - The Accreditation Council for Graduate Medical Education requires residency programs to address safe … Copy Citation Related Resources From the Same Author(s) Disclosing Medical … November 13, 2013 Patterns of communication breakdowns resulting in injury to surgical

Guideline for opioid therapy and chronic noncancer pain. | PSNet

psnet.ahrq.gov/issue/guideline-opioid-therapy-and-chronic-noncancer-pain

June 17, 2014 - Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … December 14, 2016 Prevention and treatment of bile duct injuries during laparoscopic … , 2012 Recommended guidelines for monitoring, reporting, and conducting research on medical

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