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  1. 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
  2. www.uspreventiveservicestaskforce.org/uspstf/recommendation/tuberculosis-infection-screening-immunization-1996
    February 11, 2014 - About one third of all reported cases in the U.S. occur in blacks, 20% occur in Hispanics, 14% occur … in Asians and Pacific Islanders, and 1% occur in American Indians and Alaska Natives. 2 About 30% of … new cases occur in foreign-born immigrants. 2 The prevalence in homeless persons is 1-7% for clinically … potential adverse effects of BCG vaccination include prolonged ulceration and local adenitis, which occur … Osteomyelitis and death from disseminated BCG infection are estimated to occur in one case per million
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42322/psn-pdf
    June 05, 2013 - medications in common use, due to the potential for serious bleeding complications if medication errors occur
  10. 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
  11. 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…
  12. 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
  13. 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…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867137/psn-pdf
    November 13, 2024 - Enteral nutrition: an underappreciated source of patient safety events. November 13, 2024 Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events. Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153. https://psnet.ahrq.gov/issue/enteral-nutrition-underapprec…
  15. 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.…
  16. 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…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73067/psn-pdf
    March 24, 2021 - Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. March 24, 2021 LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89…
  18. 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…
  19. TND-0775-150722 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0775-150722.pdf
    May 12, 2015 - TND-0775-150722 Treatments for Adults with Schizophrenia Nomination Summary Document Results of Topic Selection Process & Next Steps § This topic will go forw…
  20. hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit5_2.jsp
    January 01, 2009 - Facts and Figures Exhibit 5.2 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …