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Search results for "State Governments and Agencies"
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Special or Theme Issue
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
Sparnon E. PA-PSRS Patient Saf Advis. September 2013;10:92-95.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this article reviews the unintended consequences of automated default values, including errors in the electronic medical record and medication administration delays.
PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50.
This failure mode and effects analysis (FMEA) explores factors contributing to near miss and adverse events related to alarm response and provides strategies to prevent monitoring failures.
Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.
Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.
Analyzing patient charts at six community hospitals in Massachusetts, this report reveals to what extent adopting computerized physician order entry could affect clinical outcomes and impart financial savings.
Journal Article > Study
Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system.
Hougland P, Xu W, Pickard S, Masheter C, Williams SD. Med Care. 2006;44:629-636.
This Agency for Healthcare Research and Quality (AHRQ)–supported study evaluated the effectiveness of using designated ICD-9 codes to detect adverse drug events (ADEs). Investigators convened an expert panel to identify codes representing ADEs and then performed retrospective chart reviews with a structured tool to determine the success of this methodology. Overall, flagged ADE codes detected just more than half of ADEs causing hospital admission, making it a readily available tool but not a comprehensive one. Past studies have evaluated the use of ICD-9 codes for similar purposes and for surveillance of device-related hazards.