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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41920/psn-pdf
    October 08, 2013 - /review-computerized-physician-handoff-tools-improving-quality-patient-care Clinical care handoffs occur
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37960/psn-pdf
    September 24, 2010 - order to maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur
  3. 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
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47105/psn-pdf
    August 10, 2018 - residents are frequently exposed to inappropriate medications and that adverse drug events (ADEs) occur
  7. Psn-Pdf (pdf file)

    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
  8. Psn-Pdf (pdf file)

    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
  9. Psn-Pdf (pdf file)

    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
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36833/psn-pdf
    March 03, 2011 - achieving-national-quality-forums-never-events-prevention-wrong-site-wrong- procedure-and Wrong site operations are rare and often occur
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40477/psn-pdf
    March 23, 2012 - The investigators estimate that nearly 4.5 million ambulatory visits occur yearly due to ADEs, with
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44552/psn-pdf
    June 21, 2016 - about misdiagnosis and developing validated metrics to determine how frequently diagnostic errors occur
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Ff 2009 Exhibit5 2 (pdf file)

    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.…
  19. Psn-Pdf (pdf file)

    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…
  20. 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…