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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - value-based payment
programs to include new metrics focused on diagnostic accuracy and hospital harms, captured
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psnet.ahrq.gov/node/837499/psn-pdf
June 22, 2022 - Relationships between pediatric safety indicators across
a national sample of pediatric hospitals: dispelling the
myth of the "safest" hospital.
June 22, 2022
Milliren CE, Bailey G, Graham DA, et al. Relationships between pediatric safety indicators across a national
sample of pediatric hospitals: dispelling the m…
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - Some of these frustrations, which are poorly captured by overall satisfaction measures, may have direct
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psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - many of which occurred in nonprimary care settings like dental offices, and very few of which were captured
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Consequently, efforts to modernize reporting practices should focus more on ensuring that priority
events are captured
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psnet.ahrq.gov/node/45045/psn-pdf
May 25, 2016 - Developing and Testing the Health Care Safety Hotline: A
Prototype Consumer Reporting System for Patient Safety
Events. Final Report.
May 25, 2016
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality;
May 2016. AHRQ Publication No. 16-0027-EF.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/34065/psn-pdf
February 09, 2011 - Incidence and preventability of adverse drug events
among older persons in the ambulatory setting.
February 9, 2011
Gurwitz JH, Field T, Harrold LR, et al. Incidence and Preventability of Adverse Drug Events Among Older
Persons in the Ambulatory Setting. JAMA. 2003;289(9):1107-1116. doi:10.1001/jama.289.9.1107.
ht…
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psnet.ahrq.gov/node/40441/psn-pdf
July 02, 2014 - A novel approach to increase residents' involvement in
reporting adverse events.
July 2, 2014
Scott DR, Weimer M, English C, et al. A novel approach to increase residents' involvement in reporting
adverse events. Acad Med. 2011;86(6):742-746. doi:10.1097/ACM.0b013e318217e12a.
https://psnet.ahrq.gov/issue/novel-app…
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psnet.ahrq.gov/node/37480/psn-pdf
January 23, 2008 - Lost opportunities: how physicians communicate about
medical errors.
January 23, 2008
Garbutt J, Waterman AD, Kapp JM, et al. Lost Opportunities: How Physicians Communicate About Medical
Errors. Health Aff (Millwood). 2008;27(1):246-255. doi:10.1377/hlthaff.27.1.246.
https://psnet.ahrq.gov/issue/lost-opportunities…
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psnet.ahrq.gov/node/44987/psn-pdf
February 01, 2017 - International recommendations for national patient safety
incident reporting systems: an expert Delphi consensus-
building process.
February 1, 2017
Howell A-M, Burns EM, Hull L, et al. International recommendations for national patient safety incident
reporting systems: an expert Delphi consensus-building process…
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psnet.ahrq.gov/node/47571/psn-pdf
December 12, 2018 - Enhancing safety culture through improved incident
reporting: a case study in translational research.
December 12, 2018
Flott K, Nelson D, Moorcroft T, et al. Enhancing Safety Culture Through Improved Incident Reporting: A
Case Study In Translational Research. Health Aff (Millwood). 2018;37(11):1797-1804.
doi:10.1…
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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - In healthcare facilities, captured digital
images are stored, transferred, and viewed across a network
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psnet.ahrq.gov/node/45684/psn-pdf
January 01, 2020 - A multilevel analysis of U.S. hospital patient safety
culture relationships with perceptions of voluntary event
reporting.
June 29, 2017
Burlison JD, Quillivan RR, Kath LM, et al. A Multilevel Analysis of U.S. Hospital Patient Safety Culture
Relationships With Perceptions of Voluntary Event Reporting. J Patient Sa…
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psnet.ahrq.gov/node/34804/psn-pdf
January 05, 2017 - Incident reporting system does not detect adverse drug
events: a problem for quality improvement.
January 5, 2017
Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events:
a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-8.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/39802/psn-pdf
November 16, 2010 - "Water cooler" learning: knowledge sharing at the clinical
"backstage" and its contribution to patient safety.
November 16, 2010
Waring J, Bishop S. "Water cooler" learning: knowledge sharing at the clinical "backstage" and its
contribution to patient safety. J Health Organ Manag. 2010;24(4):325-42.
https://psnet.…
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psnet.ahrq.gov/node/42669/psn-pdf
September 27, 2017 - Patient-reported missed nursing care correlated with
adverse events.
September 27, 2017
Kalisch BJ, Xie B, Dabney BW. Patient-reported missed nursing care correlated with adverse events. Am J
Med Qual. 2014;29(5):415-22. doi:10.1177/1062860613501715.
https://psnet.ahrq.gov/issue/patient-reported-missed-nursing-car…
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - Handoffs and Handovers
September 13, 2021
Anonymous (not verified)
See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …
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psnet.ahrq.gov/node/47457/psn-pdf
January 17, 2019 - Developing a reporting culture: learning from close calls
and hazardous conditions.
January 17, 2019
Developing a reporting culture: Learning from close calls and hazardous conditions. Sentinel Event Alert.
2018;(60):1-8.
https://psnet.ahrq.gov/issue/developing-reporting-culture-learning-close-calls-and-hazardous-…
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psnet.ahrq.gov/node/43670/psn-pdf
November 12, 2014 - Incidents resulting from staff leaving normal duties to
attend medical emergency team calls.
November 12, 2014
Investigators CMETIS, Cheung W, Sahai V, et al. Incidents resulting from staff leaving normal duties to
attend medical emergency team calls. Med J Aust. 2014;201(9):528-31.
https://psnet.ahrq.gov/issue/in…
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psnet.ahrq.gov/node/47727/psn-pdf
January 23, 2019 - Improving resident and fellow engagement in patient
safety through a graduate medical education incentive
program.
January 23, 2019
Turner DA, Bae J, Cheely G, et al. Improving Resident and Fellow Engagement in Patient Safety Through
a Graduate Medical Education Incentive Program. J Gen Intern Care. 2018;10(6):671…