Results

Total Results: 1,110 records

Showing results for "occurrence".

221. The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System. | PSNet
     psnet.ahrq.gov/issue/high-costs-weak-compliance-new-york-state-hospital-adverse-event-reporting-and-tracking
     July 22, 2020 - This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking

222. Real-time debriefing after critical events: exploring the gap between principle and reality. | PSNet
     psnet.ahrq.gov/issue/real-time-debriefing-after-critical-events-exploring-gap-between-principle-and-reality
     December 15, 2021 - Debriefing is an established strategy teams use to learn from critical events , reduce event occurrence

223. Hospital-acquired infections under pay-for-performance systems: an administrative perspective on management and change. | PSNet
     psnet.ahrq.gov/issue/hospital-acquired-infections-under-pay-performance-systems-administrative-perspective
     January 30, 2019 - This review examines the impact of financial incentives on occurrence of hospital-acquired infections

224. Representative case series from public hospital admissions 1998 II: surgical adverse events. | PSNet
     psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical-adverse-events
     June 07, 2023 - The authors analyzed surgical adverse events to assess the occurrence, cause, patient impact, and preventability

225. Adverse events and near miss reporting in the NHS. | PSNet
     psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
     August 30, 2023 - Discussion includes detailed presentation of the frequency of events, their location of occurrence, and

226. The relationship between registered nurses and nursing home quality: an integrative review (2008–2014). | PSNet
     psnet.ahrq.gov/issue/relationship-between-registered-nurses-and-nursing-home-quality-integrative-review-2008-2014
     June 03, 2020 - Adverse events in the nursing home setting are a common , and often preventable, occurrence.

227. 1,300 days and counting: a risk model approach to preventing retained foreign objects (RFOs). | PSNet
     psnet.ahrq.gov/issue/1300-days-and-counting-risk-model-approach-preventing-retained-foreign-objects-rfos
     April 12, 2019 - This commentary describes how one organization reduced the occurrence of this surgical complication.

228. Can you prevent adverse drug events after hospital discharge? | PSNet
     psnet.ahrq.gov/issue/can-you-prevent-adverse-drug-events-after-hospital-discharge
     September 09, 2009 - cases of postdischarge adverse drug events, as well as actions physicians can take to minimize their occurrence

229. Profiles in patient safety: confirmation bias in emergency medicine. | PSNet
     psnet.ahrq.gov/issue/profiles-patient-safety-confirmation-bias-emergency-medicine
     November 23, 2016 - suggests automation, cognitive forcing strategies, and metacognition as strategies to minimize its occurrence

230. How a series of errors led to recurrent hypoglycemia. | PSNet
     psnet.ahrq.gov/issue/how-series-errors-led-recurrent-hypoglycemia
     April 23, 2014 - illustrates how therapeutic duplication can lead to harm and provides several strategies to minimize its occurrence

231. Considering insulin pens for routine hospital use? Consider this... | PSNet
     psnet.ahrq.gov/issue/considering-insulin-pens-routine-hospital-use-consider
     May 03, 2023 - January 5, 2017 Tubing misconnections—a persistent and potentially deadly occurrence.

232. Double key bounce and double keying errors. | PSNet
     psnet.ahrq.gov/issue/double-key-bounce-and-double-keying-errors
     February 01, 2023 - January 5, 2017 Tubing misconnections—a persistent and potentially deadly occurrence.

233. Exploring the experience of nurse practitioners who have committed medical errors: a phenomenological approach. | PSNet
     psnet.ahrq.gov/issue/exploring-experience-nurse-practitioners-who-have-committed-medical-errors-phenomenological
     April 21, 2021 - October 12, 2016 The occurrence of adverse events potentially attributable to nursing

234. IV potassium given epidurally: getting to the "route" of the problem. | PSNet
     psnet.ahrq.gov/issue/iv-potassium-given-epidurally-getting-route-problem
     April 20, 2022 - April 25, 2018 Tubing misconnections—a persistent and potentially deadly occurrence.

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39948/psn-pdf
     December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences. December 21, 2014 Stahel PF, Sabel A, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of p…

236. Examples of Medical Device Misconnections. | PSNet
     psnet.ahrq.gov/issue/examples-medical-device-misconnections
     March 04, 2015 - therapeutic agent administration failures, despite efforts to redesign equipment and minimize their occurrence

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42454/psn-pdf
     September 09, 2013 - perinatal-care-quality-and-safety-initiative-are-there-financial-rewards-improved-quality https://psnet.ahrq.gov/issue/relationship-between-occurrence-surgical-complications-and-hospital-finances

238. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
     May 01, 2012 - approaches to measuring adverse event rates have been used, including voluntary reports ("incident" or "occurrence … Occurrence reports : The most well known strategy to identify and measure patient safety in U.S. hospitals … is the use of occurrence ("incident") reports submitted by caregivers. … Although these data are relatively easy and inexpensive to obtain, evidence suggests that occurrence … characteristics than other measurement approaches and detect significantly more adverse events than occurrence

239. In Conversation With…David C. Classen, MD, MS | PSNet
     psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
     May 01, 2012 - Occurrence reports : The most well known strategy to identify and measure patient safety in U.S. hospitals … is the use of occurrence ("incident") reports submitted by caregivers. … Although these data are relatively easy and inexpensive to obtain, evidence suggests that occurrence … characteristics than other measurement approaches and detect significantly more adverse events than occurrence … table citation in the text) Harm Detection Method Advantages Limitations Incident (occurrence

240. Diagnostic overshadowing among groups experiencing health disparities. | PSNet
     psnet.ahrq.gov/issue/diagnostic-overshadowing-among-groups-experiencing-health-disparities
     February 10, 2021 - December 23, 2016 Tubing misconnections—a persistent and potentially deadly occurrence