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psnet.ahrq.gov/node/41595/psn-pdf
May 28, 2019 - Luer Connector Misconnections: Under-Recognized but
Potentially Dangerous Events.
May 28, 2019
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. November 19,
2008.
https://psnet.ahrq.gov/issue/luer-connector-misconnections-under-recognized-potentially-dangerous-events
This Web si…
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psnet.ahrq.gov/node/37591/psn-pdf
November 10, 2011 - Commentary on Sentinel & Serious Events Reported by
District Health Boards - 2006/07.
November 10, 2011
National Health Epidemiology and Quality Assurance Advisory Committee. Wellington, New Zealand;
Quality Improvement Committee; 2008.
https://psnet.ahrq.gov/issue/commentary-sentinel-serious-events-reported-distr…
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psnet.ahrq.gov/issue/growing-role-patient-safety-officer-implications-risk-managers
February 17, 2009 - Book/Report
The growing role of the Patient Safety Officer: implications for risk managers.
Citation Text:
The growing role of the Patient Safety Officer: implications for risk managers. Chicago, IL: American Society of Healthcare Risk Management; 2004.
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psnet.ahrq.gov/issue/girl-dies-during-restraint-hospital-already-criticized-problems
March 16, 2011 - Newspaper/Magazine Article
A girl dies during restraint at hospital already criticized for problems.
Citation Text:
A girl dies during restraint at hospital already criticized for problems. Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
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psnet.ahrq.gov/issue/patient-safety-and-quality-pediatric-intensive-care-unit
October 06, 2011 - Special or Theme Issue
Patient safety and quality in the pediatric intensive care unit.
Citation Text:
Patient safety and quality in the pediatric intensive care unit. Ped Crit Care Med. 2007;8(2):s1-s43.
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psnet.ahrq.gov/training-catalog/monthly-webinars
Organization:
Organization
Quality Reporting Center
Event … Event Location: Online
Date: On demand
Event Fee: Free
CE or CME Offered?
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - allows any provider to submit an online report of any situation that
created a near miss for an adverse event … or actually caused an adverse event.
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psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - actually looking through the charts, and an expert panel that would then determine whether an adverse event … Teaching dental students about patient communication following an adverse event: a pilot educational … An adverse event trigger tool in dentistry: a new methodology for measuring harm in the dental office
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psnet.ahrq.gov/node/38393/psn-pdf
October 03, 2017 - Adverse Health Care Events Reporting System: What
Have We Learned?
October 3, 2017
St. Paul, MN: Minnesota Department of Health; January 2009.
https://psnet.ahrq.gov/issue/adverse-health-care-events-reporting-system-what-have-we-learned
Through a qualitative evaluation of the Minnesota statewide reporting initiati…
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psnet.ahrq.gov/node/38375/psn-pdf
December 01, 2019 - ISMP QuarterWatch Reports.
April 17, 2019
Horsham, PA: Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-quarterwatch-reports
This website provides quarterly reports that identify and analyze new risks related to medications and
adverse drug events submitted to the Food and Drug Administra…
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psnet.ahrq.gov/training-catalog/armstrong-institute-training-catalog
Johns Hopkins Armstrong Institute for Patient Safety and Quality
Event … Description: Collection of patient safety training modules
Event Location: Online
Date: … On demand
Event Fee: Fee Associated
CE or CME Offered?
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psnet.ahrq.gov/training-catalog/webinar-series-3
Organization:
Organization
Hospital Quality Institute
Event … Event Location: Online
Date: On demand
Event Fee: Free
CE or CME Offered?
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psnet.ahrq.gov/training-catalog/webinar-series
Organization:
Organization
Patient Safety Authority
Event … Event Location: Online
Date: Various dates
Event Fee: Free
CE or CME Offered?
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psnet.ahrq.gov/node/38308/psn-pdf
April 21, 2010 - Adverse-event-reporting practices by US hospitals:
results of a national survey. … Adverse-event-reporting practices by US hospitals: results of
a national survey. … https://psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey … https://psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey
https
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psnet.ahrq.gov/periodic-issue/periodic-issue-386
April 26, 2023 - Study
Using the Generic Analysis Method to analyze sentinel event reports across … This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing
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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - Source of New Failures
Just a few years ago, prior to development of digital radiology, this type of event … The source of this event is not human error on the part of the surgeon.
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psnet.ahrq.gov/node/40038/psn-pdf
December 23, 2016 - Sentinel Event Alert. 2010;46(46):1-4. … follow-report-preventing-suicide-focus-medicalsurgical-units-and-emergency-
department
Suicide among hospitalized patients remains an under-recognized never event … This Sentinel Event Alert reviews risk factors for inpatient suicide and
delineates prevention strategies … never-events
https://psnet.ahrq.gov/issue/suicide-medical-setting
https://psnet.ahrq.gov/issue/sentinel-event-alert
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psnet.ahrq.gov/training-catalog/ashp-learning-center
Organization
American Society for Health-System Pharmacists (ASHP)
Event … Event Location: Online
Date: On demand
Event Fee: Fee Associated (for some)
CE or CME Offered
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psnet.ahrq.gov/node/39736/psn-pdf
April 03, 2017 - Risk and Event Assessment.
April 3, 2017
Jt Comm J Qual Patient Saf. 2010;36:348-385. … https://psnet.ahrq.gov/issue/risk-and-event-assessment
This issue contains several articles dedicated … https://psnet.ahrq.gov/issue/risk-and-event-assessment
https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its
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psnet.ahrq.gov/training-catalog/pharmacy-education-opportunities
Organization
National Community Pharmacists Association (NCPA)
Event … Event Location: Online
Date: On demand
Event Fee: Fee Associated
CE or CME Offered?