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Total Results: over 10,000 records

Showing results for "occurring".

4481. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. | PSNet
      psnet.ahrq.gov/issue/unintended-discontinuation-medication-following-hospitalisation-retrospective-cohort-study
      September 05, 2018 - Study Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. Citation Text: Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. d…

4482. A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet
      psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
      June 13, 2011 - Review A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. Citation Text: Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…

4483. Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. | PSNet
      psnet.ahrq.gov/issue/radiologists-make-more-errors-interpreting-hours-body-ct-studies-during-overnight-assignments
      November 16, 2022 - Study Radiologists make more errors interpreting off-hours body CT studies during overnight assignments as compared with daytime assignments. Citation Text: Patel AG, Pizzitola VJ, Johnson CD, et al. Radiologists Make More Errors Interpreting Off-Hours Body CT Studies during Overnight As…

4484. Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety. | PSNet
      psnet.ahrq.gov/issue/shape-matters-neglected-feature-medication-safety-why-regulating-shape-medication-containers
      December 09, 2020 - Commentary Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety. Citation Text: Bitan Y, Nunnally M. Shape matters: a neglected feature of medication safety: why regulating the shape of medication contain…

4485. Race differences in reported harmful patient safety events in healthcare system high reliability organizations. | PSNet
      psnet.ahrq.gov/issue/race-differences-reported-harmful-patient-safety-events-healthcare-system-high-reliability
      March 01, 2023 - Study Race differences in reported harmful patient safety events in healthcare system high reliability organizations. Citation Text: Thomas AD, Pandit C, Krevat SA. Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations. J Patient S…

4486. Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study. | PSNet
      psnet.ahrq.gov/issue/evolving-quality-improvement-support-strategies-improve-plan-do-study-act-cycle-fidelity
      March 17, 2014 - Study Emerging Classic Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study. Citation Text: McNicholas C, Lennox L, Woodcock T, et al. Evolving quality improvement support strategies to …

4487. Barriers to the implementation of checklists in the office-based procedural setting. | PSNet
      psnet.ahrq.gov/issue/barriers-implementation-checklists-office-based-procedural-setting
      February 18, 2019 - Study Barriers to the implementation of checklists in the office-based procedural setting. Citation Text: Shapiro FE, Fernando RJ, Urman RD. Barriers to the implementation of checklists in the office-based procedural setting. J Healthc Risk Manag. 2014;33(4):35-43. doi:10.1002/jhrm.21141…

4488. Workplace training for senior trainees: a systematic review and narrative synthesis of current approaches to promote patient safety. | PSNet
      psnet.ahrq.gov/issue/workplace-training-senior-trainees-systematic-review-and-narrative-synthesis-current
      February 07, 2024 - Review Workplace training for senior trainees: a systematic review and narrative synthesis of current approaches to promote patient safety. Citation Text: Walton M, Harrison R, Burgess A, et al. Workplace training for senior trainees: a systematic review and narrative synthesis of curren…

4489. "Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. | PSNet
      psnet.ahrq.gov/issue/mr-smiths-been-our-problem-child-today-anticipatory-management-communication-amc-va-end-shift
      January 22, 2016 - Study "Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. Citation Text: Bergman AA, Flanagan ME, Ebright PR, et al. "Mr Smith's been our problem child today…": anticipatory management communication (…

4490. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. | PSNet
      psnet.ahrq.gov/issue/empowering-frontline-nurses-structured-intervention-enables-nurses-improve-medication
      March 13, 2012 - Study Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Citation Text: Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accur…

4491. A new category of "never events"-ending harmful hospital policies. | PSNet
      psnet.ahrq.gov/issue/new-category-never-events-ending-harmful-hospital-policies
      September 07, 2022 - Commentary A new category of "never events"-ending harmful hospital policies. Citation Text: Chokshi DA, Beckman AL. A new category of "never events"-ending harmful hospital policies. JAMA Health Forum. 2022;3(10):e224703. doi:10.1001/jamahealthforum.2022.4703. Copy Citation Format…

4492. Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project. | PSNet
      psnet.ahrq.gov/issue/patient-safety-external-beam-radiotherapy-guidelines-risk-assessment-and-analysis-adverse
      March 15, 2017 - Study Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project. Citation Text: Malicki J, Bly R, Bulot M, et al. Patient safety in external beam radiotherapy - guidelines on risk asses…

4493. Assessment of emergency department antibiotic discharge prescription dosing errors for pediatric patients in a community hospital health system. | PSNet
      psnet.ahrq.gov/issue/assessment-emergency-department-antibiotic-discharge-prescription-dosing-errors-pediatric
      March 01, 2011 - Study Assessment of emergency department antibiotic discharge prescription dosing errors for pediatric patients in a community hospital health system. Citation Text: Barstow L, Herman E, Phillips H, et al. Assessment of Emergency Department Antibiotic Discharge Prescription Dosing Errors…

4494. Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. | PSNet
      psnet.ahrq.gov/issue/improving-medication-administration-safety-using-naive-observation-assess-practice-and-guide
      October 06, 2016 - Study Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. Citation Text: Donaldson N, Aydin C, Fridman M, et al. Improving medication administration safety: using naïve observation to assess practice and g…

4495. Misleading one detail: a preventable mode of diagnostic error? | PSNet
      psnet.ahrq.gov/issue/misleading-one-detail-preventable-mode-diagnostic-error
      February 10, 2016 - Study Misleading one detail: a preventable mode of diagnostic error? Citation Text: Arzy S, Brezis M, Khoury S, et al. Misleading one detail: a preventable mode of diagnostic error? J Eval Clin Pract. 2009;15(5):804-6. doi:10.1111/j.1365-2753.2008.01098.x. Copy Citation Format: …

4496. Unplanned return to theater: a quality of care and risk management index? | PSNet
      psnet.ahrq.gov/issue/unplanned-return-theater-quality-care-and-risk-management-index
      August 20, 2018 - Study Unplanned return to theater: a quality of care and risk management index? Citation Text: Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013. …

4497. Automation of the I-PASS tool to improve transitions of care. | PSNet
      psnet.ahrq.gov/issue/automation-i-pass-tool-improve-transitions-care
      August 04, 2021 - Study Automation of the I-PASS tool to improve transitions of care. Citation Text: Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174. Copy Citation Format: …

4498. Residents' numeric inputting error in computerized physician order entry prescription. | PSNet
      psnet.ahrq.gov/issue/residents-numeric-inputting-error-computerized-physician-order-entry-prescription
      March 24, 2019 - Study Residents' numeric inputting error in computerized physician order entry prescription. Citation Text: Wu X, Wu C, Zhang K, et al. Residents' numeric inputting error in computerized physician order entry prescription. Int J Med Inform. 2016;88:25-33. doi:10.1016/j.ijmedinf.2016.01.0…

4499. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. | PSNet
      psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses
      August 02, 2015 - Study BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Citation Text: Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.…

4500. Case 6. Horizon Hospital—Lakeview Healthcare | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case6.html
      November 01, 2014 - and process improvement staff noted that they have seen Lean and other process improvement activities occurring … Since Horizon was still quite new during the last set of interviews and adjustments were still occurring