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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36758/psn-pdf
    August 10, 2011 - Seven hundred and fifty-nine (759) chances to learn: a 3- year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland. August 10, 2011 Lundy D, Laspina S, Kaplan H, et al. Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related ne…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44892/psn-pdf
    June 08, 2016 - Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints. June 8, 2016 Harrison R, Walton M, Healy J, et al. Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints. Int J Qual Health Care. 2016;28(2):240-5…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - the National Patient Safety Foundation (NPSF) released a report entitled RCA2: Improving Root Cause Analyses … RCA2: Improving Root Cause Analyses and Actions to Prevent Harm: 9 Recommendations From NPSF 1. … Source: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. … https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm https://psnet.ahrq.gov … /issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm https://psnet.ahrq.gov/issue/problem-root-cause-analysis

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42430/psn-pdf
    February 19, 2014 - Framework for analysing risk and safety in clinical medicine. February 19, 2014 Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154-7. https://psnet.ahrq.gov/issue/framework-analysing-risk-and-safety-clinical-medicine This commentary outlin…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867652/psn-pdf
    February 26, 2025 - https://psnet.ahrq.gov/primer/culture-safety https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm … annual-perspective-psychological-safety-healthcare-staff https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm … This adaptability allows organizations to start small or tackle complex analyses all at once, depending … RCA2: Improving root cause analyses and actions to prevent harm. … patientsafety/adverseevents/toolkit/index.html https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40756/psn-pdf
    September 07, 2011 - How reliable is your hospital? A qualitative framework for analysing reliability levels. September 7, 2011 Ikkersheim DE, Berg M. How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf. 2011;20(9):785-790. https://psnet.ahrq.gov/issue/how-reliable-your-hospital-qualit…

  7. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. | PSNet

    psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
    July 12, 2023 - Meta-analyses on provider, patient, organisational, and handoff outcomes. … June 29, 2022 Meta-analyses of the effects of standardized handoff protocols on patient

  8. Handoff mnemonics used in perioperative handoff intervention studies: a systematic review. | PSNet

    psnet.ahrq.gov/issue/handoff-mnemonics-used-perioperative-handoff-intervention-studies-systematic-review
    November 16, 2022 - Meta-analyses on provider, patient, organisational, and handoff outcomes. … July 18, 2018 Meta-analyses of the effects of standardized handoff protocols on patient

  9. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. | PSNet

    psnet.ahrq.gov/issue/medication-safety-emergency-medical-services-approaching-evidence-based-method-verification
    September 28, 2022 - July 12, 2023 Meta-analyses of the effects of standardized handoff protocols on patient … Meta-analyses on provider, patient, organisational, and handoff outcomes.

  10. Leadership and patient safety: a review of the literature. | PSNet

    psnet.ahrq.gov/issue/leadership-and-patient-safety-review-literature
    March 29, 2023 - November 6, 2013 Comparative economic analyses of patient safety improvement strategies … July 28, 2010 AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34706/psn-pdf
    December 23, 2012 - Analysing potential harm in Australian general practice: an incident-monitoring study. December 23, 2012 Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident- monitoring study. Med J Aust. 1998;169(2):73-6. https://psnet.ahrq.gov/issue/analysing-potential-harm…

  12. A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment. | PSNet

    psnet.ahrq.gov/issue/qualitative-study-why-general-practitioners-may-participate-significant-event-analysis-and
    October 29, 2008 - April 9, 2013 Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33747/psn-pdf
    March 01, 2013 - A series of recent meta-analyses has quantitatively synthesized the evidence for two common simulation … These meta-analyses collectively included more than 1000 individual studies, which enrolled well over … However, in performing these analyses, my colleagues and I observed high variability between studies … in all these analyses, suggesting that some simulation interventions are more effective in certain settings … individualized training, and longer training time significantly improve skill outcomes.(5) Similar analyses

  14. Root Cause Analysis Playbook. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-playbook
    July 05, 2017 - December 23, 2016 RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. … February 24, 2016 VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43040/psn-pdf
    March 05, 2014 - Framework for analysing risk and safety in clinical medicine. March 5, 2014 Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154-1157. https://psnet.ahrq.gov/issue/framework-analysing-risk-and-safety-clinical-medicine-0 This commentary outli…

  16. Public opinion of resident physician work hours in 2022. | PSNet

    psnet.ahrq.gov/issue/public-opinion-resident-physician-work-hours-2022
    April 19, 2023 - Systematic review of the impact of physician work schedules on patient safety with meta-analyses … Systematic review of the impact of physician work schedules on patient safety with meta-analyses

  17. Sharing lessons learned to prevent adverse events in anesthesiology nationwide. | PSNet

    psnet.ahrq.gov/issue/sharing-lessons-learned-prevent-adverse-events-anesthesiology-nationwide
    April 12, 2019 - August 18, 2010 Root cause analyses of reported adverse events occurring during gastrointestinal … October 18, 2023 Root cause analyses of reported adverse events occurring during gastrointestinal

  18. Checking all the boxes: a checklist for when and how to use checklists effectively. | PSNet

    psnet.ahrq.gov/issue/checking-all-boxes-checklist-when-and-how-use-checklists-effectively
    June 29, 2022 - September 28, 2022 Meta-analyses of the effects of standardized handoff protocols on … Meta-analyses on provider, patient, organisational, and handoff outcomes.

  19. How reliable is your hospital? A qualitative framework for analysing reliability levels. | PSNet

    psnet.ahrq.gov/issue/how-reliable-your-hospital-qualitative-framework-analysing-reliability-levels
    October 19, 2022 - Commentary How reliable is your hospital? A qualitative framework for analysing reliability levels. Citation Text: Ikkersheim DE, Berg M. How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf. 2011;20(9):785-790. Copy Citation Format…

  20. Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. | PSNet

    psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center-transforming-healthcare
    October 19, 2016 - January 3, 2017 RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. … February 17, 2016 VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses
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