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Total Results: 1,109 records

Showing results for "occurrence".

861. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35161/psn-pdf
     March 13, 2016 - The forgotten tourniquet—an update. March 13, 2016 PA Patient Saf Advis. 2016;13(1):4. http://patientsafety.pa.gov/ADVISORIES/Pages/201603_32.aspx. https://psnet.ahrq.gov/issue/forgotten-tourniquet-update This advisory from the Pennsylvania Patient Safety Reporting System discusses 1079 reports of tourniquets bein…

862. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35932/psn-pdf
     October 03, 2017 - Injury to research volunteers—the clinical-research nightmare. October 3, 2017 Wood AJJ, Darbyshire J. Injury to research volunteers--the clinical-research nightmare. N Engl J Med. 2006;354(18):1869-71. https://psnet.ahrq.gov/issue/injury-research-volunteers-clinical-research-nightmare The authors discuss a high-…

863. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37915/psn-pdf
     January 27, 2009 - Barcode technology flaws put some patients at risk. January 27, 2009 Preidt R. ABC News. July 4, 2008. https://psnet.ahrq.gov/issue/barcode-technology-flaws-put-some-patients-risk This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides a…

864. Wrong-side thoracentesis: lessons learned from root cause analysis. | PSNet
     psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
     July 16, 2015 - Study Wrong-side thoracentesis: lessons learned from root cause analysis. Citation Text: Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146. Copy Citation Format: …

865. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38348/psn-pdf
     December 30, 2014 - Implementing a bar-code medication administration system. December 30, 2014 Weber RJ. Implementing a Bar-Code Medication Administration System. Hosp Pharm. 2010;43(12):1016- 1022. doi:10.1310/hpj4312-1016. https://psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system This commentary discusse…

866. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849613/psn-pdf
     May 31, 2023 - Smart infusion pump investigations after an unexplained over-infusion. May 31, 2023 ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3. https://psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion Dose error-reduction systems (DERS) and drug libraries are tool…

867. SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study. | PSNet
     psnet.ahrq.gov/issue/sbar-improves-communication-and-safety-climate-and-decreases-incident-reports-due
     June 01, 2016 - June 1, 2016 Occurrence of no-harm incidents and adverse events in hospitalized patients

868. Development and content validation of a surgical safety checklist for operating theatres that use robotic technology. | PSNet
     psnet.ahrq.gov/issue/development-and-content-validation-surgical-safety-checklist-operating-theatres-use-robotic
     February 25, 2015 - December 21, 2014 Minimization of occurrence of retained surgical items using machine

869. Decisions about critical events in device-related scenarios as a function of expertise. | PSNet
     psnet.ahrq.gov/issue/decisions-about-critical-events-device-related-scenarios-function-expertise
     January 02, 2017 - June 3, 2013 The nature and occurrence of registration errors in the emergency department

870. Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative. | PSNet
     psnet.ahrq.gov/issue/amid-covid-19-pandemic-meaningful-communication-between-family-caregivers-and-residents-long
     May 26, 2011 - August 19, 2020 Implementing the clinical occurrence reporting and learning system: a

871. Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care. | PSNet
     psnet.ahrq.gov/issue/soft-factors-smooth-transport-role-safety-climate-and-team-processes-reducing-adverse-events
     September 27, 2016 - : how patient engagement and safety climate jointly affect error occurrence in hospital units.

872. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42767/psn-pdf
     November 27, 2013 - Barcode medication administration work-arounds: a systematic review and implications for nurse executives. November 27, 2013 Voshall B, Piscotty R, Lawrence J, et al. Barcode medication administration work-arounds: a systematic review and implications for nurse executives. J Nurs Adm. 2013;43(10):530-535. doi:10.1…

873. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46593/psn-pdf
     November 08, 2017 - Unreadable barcodes and multiple barcodes on packages can lead to errors. November 8, 2017 ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3. https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors Barcodes can both enhance and degrade the medication …

874. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836915/psn-pdf
     April 13, 2022 - Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review. April 13, 2022 Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical Electronic Health Record workaround…

875. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45249/psn-pdf
     June 22, 2016 - PHSO Review: Quality of NHS Complaints Investigations. June 22, 2016 First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94. https://psnet.ahrq.gov/issue/phso-review-quality-nhs-comp…

876. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838243/psn-pdf
     October 05, 2022 - Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology. October 5, 2022 Fuller AEC, Guirguis LM, Sadowski CA, et al. Evaluation of medication incidents in a long-term care facility using electronic medication administration records …

877. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46101/psn-pdf
     January 01, 2018 - Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review. December 19, 2017 Strudwick G, Reisdorfer E, Warnock C, et al. Factors Associated With Barcode Medication Administration Technology That Contribute to Patient Safety: An Integrative Review…

878. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38721/psn-pdf
     June 25, 2009 - Effect of bar-code–assisted medication administration on medication error rates in an adult medical intensive care unit. June 25, 2009 DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on medication error rates in an adult medical intensive care unit. Am J Health Syst Ph…

879. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47044/psn-pdf
     April 18, 2018 - Bedside computer vision—moving artificial intelligence from driver assistance to patient safety. April 18, 2018 Yeung S, Downing L, Fei-Fei L, et al. Bedside Computer Vision - Moving Artificial Intelligence from Driver Assistance to Patient Safety. New Engl J Med. 2018;378(14):1271-1273. doi:10.1056/NEJMp1716891. …

880. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44746/psn-pdf
     January 20, 2016 - Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework. January 20, 2016 Kelly K, Harrington L, Matos P, et al. Creating a Culture of Safety Around Bar-Code Medication Administration: An Evidence-Based Evaluation Framework. J Nurs Adm. 2016;46(1):30-7. doi:10…