-
psnet.ahrq.gov/node/37960/psn-pdf
September 24, 2010 - order to
maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur
-
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
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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
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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
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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
-
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
-
psnet.ahrq.gov/node/44552/psn-pdf
June 21, 2016 - about misdiagnosis and
developing validated metrics to determine how frequently diagnostic errors 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/42322/psn-pdf
June 05, 2013 - medications in common use, due to the
potential for serious bleeding complications if medication errors 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/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…
-
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
-
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…
-
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…
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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…
-
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…
-
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…
-
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…
-
hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit5_2.jsp
January 01, 2009 - Facts and Figures Exhibit 5.2
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