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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Devices Devices are any type of equipment or tools that have designated functions used during a procedure … or device fragment and (2) keeps a record of cases to identify trends and patterns (for example, by type … of procedure, by type of retained item, by manufacturer, by practitioner) that may highlight opportunities … (30%) involved SMI and device fragments. 9 cases (11%) involved instruments. 7/9 cases involved one type … reported to internal facility reporting systems (with drill bits lodged in bone as the most common type
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - The immune response varies with the dose, frequency of administration, and type of the toxin used.( 7 … patients who develop genuine antibody-mediated resistance to botulinum neurotoxin, switching to another type … Information about the indication, goals, adverse effects, type, and dose of botulinum toxin injections … Neutralizing antibodies and secondary therapy failure after treatment with botulinum toxin type A: much
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psnet.ahrq.gov/issue/types-and-patterns-safety-concerns-home-care-client-and-family-caregiver-perspectives
December 29, 2014 - Study
Types and patterns of safety concerns in home care: client and family caregiver perspectives.
Citation Text:
Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):21…
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psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and
April 06, 2011 - Study
Classic
Communication failures in the operating room: an observational classification of recurrent types and effects.
Citation Text:
Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recu…
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psnet.ahrq.gov/node/837637/psn-pdf
July 06, 2022 - This study found that a hospital’s internal policies about admission type introduces variation
in PSI
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psnet.ahrq.gov/node/73377/psn-pdf
June 09, 2021 - examination-factors-predict-perioperative-culture-safety
Prior research identified variability in perioperative safety culture by provider type
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psnet.ahrq.gov/node/41623/psn-pdf
April 05, 2013 - Preventing patient harms through systems of care.
April 5, 2013
Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70.
doi:10.1001/jama.2012.9537.
https://psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care
Recent initiatives, such as the Partnership for…
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psnet.ahrq.gov/node/862602/psn-pdf
February 14, 2024 - Findings
indicate that prescribing errors (e.g., dosing errors) are the most common type of medication
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psnet.ahrq.gov/issue/patients-perception-types-errors-palliative-care-results-qualitative-interview-study
December 04, 2016 - February 10, 2016
Frequency and type of situational awareness errors contributing to
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psnet.ahrq.gov/node/846149/psn-pdf
March 15, 2023 - Event type, severity, medication
class, and method of detection are described.
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psnet.ahrq.gov/node/837599/psn-pdf
June 29, 2022 - six hospitals and different clinical
departments and found that hospitals differed in the number and type
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psnet.ahrq.gov/node/866158/psn-pdf
June 19, 2024 - The most common type of
injury in both ASC and HOR was dental injury followed by nerve damage.
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psnet.ahrq.gov/node/867598/psn-pdf
January 22, 2025 - framework, the research team found poor alignment
between the underlying causes of the events and the type
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psnet.ahrq.gov/node/867521/psn-pdf
April 01, 2024 - The most commonly reported event type
were errors related to procedures, tests or treatments (accounting
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psnet.ahrq.gov/node/867388/psn-pdf
December 18, 2024 - Stratifying
by clinician type, the association was observed only for attending physicians.
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psnet.ahrq.gov/node/866436/psn-pdf
August 07, 2024 - study describes a new method of ensuring the appropriate medication is selected by requiring
users to type
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psnet.ahrq.gov/node/866279/psn-pdf
July 10, 2024 - seen-through-patients-eyes-safety-chronic-illness-care
https://psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type
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psnet.ahrq.gov/node/867751/psn-pdf
March 12, 2025 - Using three triggers and the Revised Safer Dx
Instrument, this study uncovered the frequency, type,
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psnet.ahrq.gov/issue/adverse-drug-events-after-hospital-discharge-older-adults-types-severity-and-involvement
August 11, 2010 - Study
Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.
Citation Text:
Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults: types, severity, and involvement of …
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psnet.ahrq.gov/node/46632/psn-pdf
May 11, 2019 - The authors advocate for conducting this type of rigorous user testing to ensure
electronic health record