-
digital.ahrq.gov/sites/default/files/docs/publication/action-qi-cds-tool-specifications.pdf
June 16, 2021 - However, the
assessment only
needs to occur
once during the
first 24 hours, not
on each unit, for … However, the
assessment only
needs to occur
once during the
first 24 hours, not
on each unit, for … However, the
assessment only
needs to occur
once during the
24 hours, and not
necessarily on
each … However, the
assessment only
needs to occur
once during the
24 hours, and not
necessarily on
each
-
digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhatIsWorkflow.ppt
January 01, 2009 - It can occur at different and/or multiple levels (e.g., one person, between people, across organizations … )
It can occur sequentially and/or simultaneously
Work flows in different ways
Inter-organizational
-
hcup-us.ahrq.gov/db/state/siddist/NewYork2005-2006SIDandSASD.pdf
January 01, 2005 - The duplicate records, while rare, occur in multiple hospitals across the State
of New York.
-
psnet.ahrq.gov/node/41920/psn-pdf
October 08, 2013 - /review-computerized-physician-handoff-tools-improving-quality-patient-care
Clinical care handoffs occur
-
psnet.ahrq.gov/node/37960/psn-pdf
September 24, 2010 - order to
maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur
-
psnet.ahrq.gov/node/36549/psn-pdf
March 21, 2017 - shown that patients are concerned about medical errors and desire full disclosure of
errors when they occur
-
psnet.ahrq.gov/node/44098/psn-pdf
April 29, 2015 - the authors suggest that current frameworks must be adapted to understand
these incidents when they occur
-
psnet.ahrq.gov/node/47105/psn-pdf
August 10, 2018 - residents are frequently exposed to inappropriate medications
and that adverse drug events (ADEs) occur
-
psnet.ahrq.gov/node/47118/psn-pdf
August 08, 2018 - wrong-site-nerve-blocks-systematic-literature-review-guide-principles-
prevention
Wrong-site procedures are considered never events, yet they continue to occur
-
psnet.ahrq.gov/node/37533/psn-pdf
April 22, 2011 - Systematic evaluation of errors occurring during the
preparation of intravenous medication.
April 22, 2011
Parshuram CS, To T, Seto W, et al. Systematic evaluation of errors occurring during the preparation of
intravenous medication. CMAJ. 2008;178(1):42-8. doi:10.1503/cmaj.061743.
https://psnet.ahrq.gov/issue/sys…
-
digital.ahrq.gov/sites/default/files/docs/publication/r18hs018183-weiner-final-report-2013.pdf
January 01, 2013 - Most medication errors occur at transitions in care, such
as when patients are admitted from ambulatory … number and fraction of outpatient medications prescribed or
addressed as to why prescribing did not occur … cases where any outpatient medications were not prescribed or
addressed as to why prescribing did not occur … Most medication errors that occur when
patients are discharged to ambulatory environments occur because
-
psnet.ahrq.gov/node/60980/psn-pdf
January 01, 2022 - Analysis of risk factors for patient safety events occurring
in the emergency department.
October 7, 2020
Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the
emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097/pts.0000000000000715.
https://p…
-
psnet.ahrq.gov/node/35876/psn-pdf
June 18, 2013 - External Inquiry into the adverse incident that occurred at
Queen's Medical Centre, Nottingham, 4th January 2001.
June 18, 2013
Toft B. London, UK; Crown Copyright: 2001.
https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham-
4th-january-2001
This UK Department o…
-
psnet.ahrq.gov/node/42993/psn-pdf
March 19, 2014 - Baccalaureate nursing students' accounts of medical
mistakes occurring in the clinical setting: implications for
curricula.
March 19, 2014
Noland CM. Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting:
implications for curricula. J Nurs Educ. 2014;53(3):S34-7. doi:10.392…
-
psnet.ahrq.gov/node/37156/psn-pdf
October 06, 2011 - Preventable harm occurring to critically ill children.
October 6, 2011
Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit
Care Med. 2007;8(4):331-336.
https://psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
This retrospective cohort…
-
psnet.ahrq.gov/node/39743/psn-pdf
October 13, 2010 - Anatomy and pathophysiology of errors occurring in
clinical radiology practice.
October 13, 2010
Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors
occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. doi:10.1148/rg.305105013.
https://psnet…
-
psnet.ahrq.gov/node/37155/psn-pdf
October 06, 2011 - Classification of adverse events occurring in a surgical
intensive care unit.
October 6, 2011
Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care
unit. Am J Surg. 2007;194(3):328-32.
https://psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgi…
-
hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_exhibit5_2.pdf
January 01, 2009 - 5.2A
HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2009 65
EXHIBIT 5.2 Common Conditions During Hospital Stays for Females
5.3
6.4
1.1
1.21.4
1.91.5
1.91.9
2.13.1
2.7
2.2
2.1
4.6
0
5
10
15
20
25
Male Stays
16.4 Million Stays
(42% of All Stays)
Female Stays
22.…
-
psnet.ahrq.gov/node/38360/psn-pdf
March 18, 2010 - Medication errors occurring with the use of bar-code
administration technology.
March 18, 2010
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
https://psnet.ahrq.gov/issue/medication-errors-occurring-use-bar-code-administration-technology
This article describes errors associated with bar coded medication admin…
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/child-maltreatment-interventions-draft-rec-bulletin.pdf
September 25, 2023 - U.S. Preventive Services Task Force Issues Draft Recommendation Statement on Primary Care Interventions to Prevent Child Maltreatment
www.uspreventiveservicestaskforce.org 1
U.S. Preventive Services Task Force Issues Draft Recommendation
Statement on Primary Care Interventions to Prevent
Child Maltreatmen…