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psnet.ahrq.gov/node/73291/psn-pdf
May 19, 2021 - How can never event data be used to reflect or improve
hospital safety performance? … How can never event data be used to reflect or improve
hospital safety performance? … https://psnet.ahrq.gov/issue/how-can-never-event-data-be-used-reflect-or-improve-hospital-safety-
performance … The
authors suggest that regulators focus on reducing the national never event rate through shared learning … https://psnet.ahrq.gov/issue/how-can-never-event-data-be-used-reflect-or-improve-hospital-safety-performance
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … Host event analysis training using tools from CANDOR.
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pcmh.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … Host event analysis training using tools from CANDOR.
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psnet.ahrq.gov/node/74172/psn-pdf
December 08, 2021 - Differences in safety report event types submitted by
graduate medical education trainees compared with … Differences in Safety Report Event Types Submitted by Graduate
Medical Education Trainees Compared With … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education … -
trainees-compared
Adverse event reporting by health care providers, including medical trainees, is … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education-trainees-compared
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psnet.ahrq.gov/node/846760/psn-pdf
March 29, 2023 - Electronic health record-based prediction models for in-
hospital adverse drug event diagnosis or prognosis … Electronic health record-based prediction
models for in-hospital adverse drug event diagnosis or prognosis … https://psnet.ahrq.gov/issue/electronic-health-record-based-prediction-models-hospital-adverse-drug-event … several challenges related to electronic health record
(EHR)-based prediction models for adverse drug event … https://psnet.ahrq.gov/issue/electronic-health-record-based-prediction-models-hospital-adverse-drug-event-diagnosis-or
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psnet.ahrq.gov/node/842770/psn-pdf
January 18, 2023 - A multi-site assessment of inpatient safety event rates
during the coronavirus disease 2019 pandemic … A multi-site assessment of inpatient safety event rates during
the coronavirus disease 2019 pandemic … https://psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease … but they did observe a relationship
between staffing levels during the pandemic and patient safety event … https://psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease
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psnet.ahrq.gov/node/841144/psn-pdf
December 07, 2022 - Using community detection techniques to identify themes
in COVID-19-related patient safety event reports … Using community detection techniques to identify themes in
COVID-19-related patient safety event reports … psnet.ahrq.gov/issue/using-community-detection-techniques-identify-themes-covid-19-related-
patient-safety-event … This study used machine learning to group of more than 2,000 patient
safety event (PSE) reports into … https://psnet.ahrq.gov/issue/patient-safety-concerns-covid-19-related-events-study-343-event-reports
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psnet.ahrq.gov/node/837307/psn-pdf
June 01, 2022 - Adverse event reviews in healthcare: what matters to
patients and their family? … Adverse event reviews in healthcare: what matters to patients
and their family? … https://psnet.ahrq.gov/issue/adverse-event-reviews-healthcare-what-matters-patients-and-their-family- … This qualitative study explored the
experiences of patients and family members involved in adverse event … outline eight key recommendations to address
these themes by involving patients and families in adverse event
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psnet.ahrq.gov/node/74751/psn-pdf
February 09, 2022 - A quality improvement initiative to improve patient safety
event reporting by residents. … A quality improvement initiative to improve patient safety event
reporting by residents. … https://psnet.ahrq.gov/issue/quality-improvement-initiative-improve-patient-safety-event-reporting-residents … Prior research has shown low rates of voluntary safety event reporting by resident physicians. … The QI team
identified barriers to reporting (e.g., lack of awareness of the organization’s event reporting
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psnet.ahrq.gov/node/853071/psn-pdf
August 30, 2023 - A natural language processing approach to categorise
contributing factors from patient safety event … psnet.ahrq.gov/issue/natural-language-processing-approach-categorise-contributing-factors-patient-
safety-event … This study found that natural language processing can be used to process
unstructured patient safety event … reports and reduce the burden of manually identifying and extracting
factors contributing to the event … psnet.ahrq.gov/issue/natural-language-processing-approach-categorise-contributing-factors-patient-safety-event
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … 32
U
N
C H E A L T H C A R E
U
N
C H E A L T H C A R E
Perceived barriers to event … reporting software
• Double event report submissions by 100% within three years
• Increase SOPS scores … in Feedback, Nonpunitive response and Event
Reporting by 2021
35
U
N
C H E A L T H C … Reporting Platform
Goal: To develop optimized interface for our event reporting software for event
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www.psoppc.org/psoppc_web/publicpages/supportingDocsV1.2
November 18, 2022 - For Developers/Vendors
Provide Feedback
Supporting Documents - Common Formats for Event … Reporting - Hospital Version 1.2
AHRQ's Common Formats for Event Reporting - Hospital Version 1.2 … (CFER-H V1.2) was released as three generic and nine event-specific forms. … For the most commonly occurring patient safety concerns, event specific-forms collect clinical structured … The PIF also collects demographic information and additional information about the impact of the event
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digital.ahrq.gov/principal-investigator/lazarus-ross
January 01, 2023 - Investigator
Lazarus, Ross
Project Name
Electronic Support for Public Health - Vaccine Adverse Event … Reporting System (ESP:VAERS)
Electronic Support for Public Health - Vaccine Adverse Event … Electronic Support for Public Health - Vaccine Adverse Event Reporting System (ESP:VAERS) - Final Report … Reporting System (ESP:VAERS)
Electronic Support for Public Health - Vaccine Adverse Event … Reporting System (ESP:VAERS)
Electronic Support for Public Health - Vaccine Adverse Event
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psnet.ahrq.gov/node/74694/psn-pdf
January 26, 2022 - This study
used 2018 mortality data and ICD-10-CM codes to characterize adverse event deaths in the … United States
compared to non-adverse event deaths. … The author estimates that 0.16-1.13% of deaths are attributed to
an adverse event. … Procedure-related complications contributed to the majority of adverse event deaths. … The risk of death due to adverse event was higher for younger patients and Black patients.
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psnet.ahrq.gov/node/60669/psn-pdf
July 08, 2020 - Participation in a system-thinking simulation experience
changes adverse event reporting. … Participation in a system-thinking simulation experience changes adverse event
reporting. … https://psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event … -
reporting
This study found that improvements in systems thinking increase adverse event (AE) reporting … https://psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event-reporting
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psnet.ahrq.gov/node/47090/psn-pdf
January 01, 2019 - 10,000 good catches: increasing safety event reporting in
a pediatric health care system. … June 27, 2018
Crandall KM, Almuhanna A, Cady R, et al. 10,000 Good Catches: Increasing Safety Event … https://psnet.ahrq.gov/issue/10000-good-catches-increasing-safety-event-reporting-pediatric-health-care … This study describes a quality improvement initiative to increase event reporting across a pediatric … https://psnet.ahrq.gov/issue/10000-good-catches-increasing-safety-event-reporting-pediatric-health-care-system
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psnet.ahrq.gov/node/45992/psn-pdf
January 01, 2020 - Barriers and facilitators of adverse event reporting by
adolescent patients and their families. … Barriers and Facilitators of Adverse Event Reporting by
Adolescent Patients and Their Families. … https://psnet.ahrq.gov/issue/barriers-and-facilitators-adverse-event-reporting-adolescent-patients-and-their … This qualitative study explored perceptions of adolescent patients and their
parents about adverse event … Positive perceptions of care led to participants being more willing to
report an adverse event; whereas
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psnet.ahrq.gov/training
October 06, 2007 - Event Location: Online
Date: October 6-7, 2021 Event Fee: CE or CME Offered? … Event Location: Online
Date: On demand Event Fee: Fee Associated CE or CME Offered? … Event Location: Online
Date: On demand Event Fee: Fee Associated CE or CME Offered? … Event Location: Online
Date: October 25-27, 2021 Event Fee: CE or CME Offered? … Event Location: Online
Date: On Demand Event Fee: Free CE or CME Offered?
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psnet.ahrq.gov/taxonomy/term/5371
October 06, 2007 - Event Date
October 28-31, 2021
Event Fee
Fee Associated
CE or CME Offered? … Event Date
On demand
Event Fee
Fee Associated
CE or CME Offered? … Event Date
On demand
Event Fee
Fee Associated
CE or CME Offered? … Event Date
On demand
Event Fee
Fee Associated
CE or CME Offered? … Event Date
Fall 2021
Event Fee
Fee Associated
CE or CME Offered?
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - Identify the adverse event early in the disclosure.
… Explain what is known about why the adverse event occurred; do not speculate.
… Tell the patient whether the adverse event was preventable, if known.
… Explain your role in the event to the patient/family; avoid blaming others or "the system" for the event … Consider ways to involve patients in post-event learning.