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9981. Coming Up Short: Maintaining Safety in the Face of Drug Shortages | PSNet
      psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
      November 01, 2012 - A recent study reported that 33% of medication errors attributed to LASA medications were the result … A 2013 survey was sent to 1516 directors of pharmacy, and they reported that out of 171 responses, 70.8% … reported a delay in treatment, 48.5% reported patients received suboptimal therapies, 15.8% reported … a treatment failure, and 1.2% reported a death related to various drug shortages.( 7 ) In a more recent … that the shortages impacted emergency care, 85% reported effects on anesthesia care, and 5% reported

9982. Unit-based incident reporting and root cause analysis: variation at three hospital unit types. | PSNet
      psnet.ahrq.gov/issue/unit-based-incident-reporting-and-root-cause-analysis-variation-three-hospital-unit-types
      April 14, 2011 - Resources From the Same Author(s) To what extent are adverse events found in patient records reported … April 14, 2011 The nature and causes of unintended events reported at 10 internal medicine … February 20, 2013 The nature and causes of unintended events reported at ten emergency … February 22, 2010 The nature and causes of unintended events reported at ten emergency

9983. Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports. | PSNet
      psnet.ahrq.gov/issue/identifying-patient-safety-problems-associated-information-technology-general-practice
      December 21, 2017 - August 20, 2018 National improvements in resident physician-reported patient safety after … More than algorithms: an analysis of safety events involving ML-enabled medical devices reported … Clinical safety of England's national programme for IT: a retrospective analysis of all reported … Conversation With… Lorri Zipperer, MA November 1, 2015 Preventability of voluntarily reported

9984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34791/psn-pdf
      March 28, 2005 - TR https://psnet.ahrq.gov/issue/drug-related-hospital-admissions This systematic review summarizes reported … results presented include the type of adverse effects, admissions resulting from noncompliance, and reported

9985. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37337/psn-pdf
      January 02, 2017 - issue/attitudes-toward-medical-device-use-errors-and-prevention-adverse-events This qualitative study reported … attitudes-toward-medical-device-use-errors-and-prevention-adverse-events https://psnet.ahrq.gov/issue/problems-medical-devices-may-be-severely-under-reported

9986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37742/psn-pdf
      May 07, 2008 - psnet.ahrq.gov/issue/national-survey-safe-practice-epidural-analgesia-obstetric-units Most UK obstetrics units reported … National Patient Safety Agency's guideline for safe administration of epidural analgesia, but many units reported

9987. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38272/psn-pdf
      December 10, 2008 - interprofessional-conflict-and-medical-errors-results-national-multi-specialty- survey Residents who reported … experiencing serious conflict with another care provider also reported a higher incidence of committing

9988. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42121/psn-pdf
      June 18, 2013 - //psnet.ahrq.gov/issue/what-can-hospitalized-patients-tell-us-about-adverse-events-learning-patient-reported … //psnet.ahrq.gov/issue/what-can-hospitalized-patients-tell-us-about-adverse-events-learning-patient-reported

9989. Prohibition of Excessive Overtime for Nurses Act. | PSNet
      psnet.ahrq.gov/issue/prohibition-excessive-overtime-nurses-act
      August 01, 2007 - that increase the risk of infection through respiratory droplets: a study of patient safety events reported … Patient harm resulting from medication reconciliation process failures: a study of serious events reported … August 1, 2007 Requires DHSS to make reported information about certain adverse events

9990. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35943/psn-pdf
      August 02, 2010 - follow-outpatient-test-results-survey-house-staff-practices-and-perceptions This study discovered that nearly 75% of internal medicine residents reported … The authors describe the most commonly reported barriers to timely follow-up (eg, lack of a reminder

9991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40624/psn-pdf
      July 20, 2011 - ed-handoffs-observed-practices-and-communication-errors This study found that clinically pertinent findings reported … in emergency department physician handoffs differ from what is reported in their documentation.

9992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41157/psn-pdf
      February 22, 2012 - results-national-neurosurgery-resident-survey-duty-hour-regulations This survey found that 8% of neurosurgery residents reported … being involved in a motor vehicle collision or other life-threatening event and 6% reported having

9993. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49726/psn-pdf
      March 01, 2015 - When a sentinel event, such as a wrong-site surgical incident, is reported by an accredited organization … For wrong-site surgery events reported to The Joint Commission from 2004 to 2014, the top three root … In fact, The Joint Commission sentinel event statistics database reported 1072 wrong-site surgeries … In particular, these events are voluntarily reported and likely represent only a small proportion of … Wrong-site surgery remains the second most frequent sentinel event reported to The Joint Commission.

9994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41985/psn-pdf
      October 26, 2016 - legislative-report-general-assembly-adverse-event-reporting This annual publication provides data on adverse events reported … The most common adverse events reported were pressure ulcers and fall- related injuries or deaths.

9995. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44443/psn-pdf
      September 09, 2015 - Nurses reported on standardized questions during the review of each patient, analogous to a checklist … , and gaps in prevention were reported back to physicians to rectify them.

9996. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46274/psn-pdf
      September 13, 2017 - surgeries, wrong-site procedures, wrong procedures, and procedures performed on the wrong patient reported … Orthopedic surgery accounted for 35% of the cases reported.

9997. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44230/psn-pdf
      November 09, 2015 - more than half of CRNAs worked extended duration (greater than 16 hour) shifts, and nearly one-third reported … call-shift-fatigue-and-use-countermeasures-and-avoidance-strategies-certified-registered https://psnet.ahrq.gov/issue/extended-work-duration-and-risk-self-reported-percutaneous-injuries-interns

9998. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35182/psn-pdf
      April 11, 2011 - study evaluated the impact of three independent medication safety interventions on the incidence of reported … Investigators collected data before and after the interventions and discovered a 73% reduction in reported

9999. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46170/psn-pdf
      July 12, 2017 - This survey found that more than half of pediatric intensive care unit nurses reported missing care … missed-nursing-care-pediatrics https://psnet.ahrq.gov/primer/missed-nursing-care https://psnet.ahrq.gov/issue/patient-reported-missed-nursing-care-correlated-adverse-events

10000. Psn-Pdf (pdf file)
       psnet.ahrq.gov/node/40643/psn-pdf
       July 27, 2011 - A study of the sociotechnical context through the analysis of reported medication incidents. … A study of the sociotechnical context through the analysis of reported medication incidents.