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psnet.ahrq.gov/issue/interactive-questioning-critical-care-during-handovers-transcript-analysis-communication
August 11, 2021 - Experienced providers utilized more interactive questioning, and physicians used interactive questioning … providers acquire handoff skills over time and that such techniques may be needed in education for less experienced
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psnet.ahrq.gov/issue/preventable-harm-because-outpatient-medication-errors-among-children-leukemia-and-lymphoma
January 15, 2020 - review to monitor 131 pediatric patients with leukemia or lymphoma for six months and found that 10% experienced … adverse drug events due to medication errors in the home and 42% experienced a medication error with
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psnet.ahrq.gov/issue/assessing-perceived-level-institutional-support-second-victim-after-patient-safety-event
April 07, 2021 - community teaching hospital did not feel that adequate support was available for clinicians whose patients experienced … : a narrative analysis of experienced physicians' stories of preventable error.
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psnet.ahrq.gov/issue/patient-perspectives-usefulness-artificial-intelligence-assisted-symptom-checker-cross
November 25, 2020 - Patients who had previously experienced a diagnostic error were more likely to use the tool to determine … where they should seek care than patients who had not previously experienced diagnostic error.
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psnet.ahrq.gov/issue/healthcare-workers-experiences-patient-safety-intensive-care-unit-during-covid-19-pandemic
May 01, 2024 - Intensive care units (ICU) experienced extensive, rapid reorganization at the beginning of the COVID … This qualitative study of ICU personnel uncovered multiple ways they experienced decreases in patient
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psnet.ahrq.gov/node/47777/psn-pdf
January 01, 2021 - Patients who experienced complications or safety events but did not identify
problems with their care … demonstrated a decreased risk of a nonpositive experience compared with
patients who experienced no
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psnet.ahrq.gov/node/42989/psn-pdf
May 28, 2014 - Experienced providers utilized
more interactive questioning, and physicians used interactive questioning … providers acquire handoff skills over time and that such techniques may be needed in
education for less experienced
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psnet.ahrq.gov/node/35511/psn-pdf
May 31, 2011 - measurement strategies, the investigators studied two
cohorts of anesthesia providers, including a more experienced … group with less attending supervision and a
less experienced group with more attending supervision.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
March 15, 2004 - Regardless of whether they experienced
an AO, patients who had major functional impairment at the time … Length of stay was nearly doubled for
patients who experienced an adverse occurrence. … To examine whether patients who have experienced
adverse occurrences have a greater risk of impairment … For length of stay, we found a near doubling in the median stay for patients
who experienced an adverse … an adverse occurrence, compared to similar patients
who did not experienced an adverse occurrence.
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psnet.ahrq.gov/node/35551/psn-pdf
June 08, 2010 - indicator in surgical patients, this study used a cohort of more than
44,000 to identify 200 patients who experienced … Investigators discovered that more than half of these patients experienced at least one incident or
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psnet.ahrq.gov/issue/breast-cancer-treatment-delays-socioeconomic-and-health-care-access-latent-classes-black-and
May 18, 2022 - Results from this population-based cohort show that Black women experienced both delayed treatment initiation … assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced
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psnet.ahrq.gov/issue/unintended-consequences-health-care-reform-impact-changes-payor-mix-patient-safety-indicators
March 16, 2022 - showed an overall improvement in patient safety in expansion states; however, when expansion states experienced … an increase in their safety-net burden, they also experienced significantly more safety events compared
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psnet.ahrq.gov/issue/injuries-and-after-diagnosis-cancer-nationwide-register-based-study
May 25, 2022 - This Swedish study looked at a previously unexamined aspect of safety—harm experienced by patients while … The population-based analysis found that patients experienced an increased risk of adverse events during
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psnet.ahrq.gov/issue/workplace-violence-pervasiveness-perioperative-environment-multiprofessional-survey
November 11, 2020 - This study details workplace violence experienced and witnessed by perioperative anesthesiologist assistants … More than three-quarters of participants reported having experienced or witnessed some form of workplace
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psnet.ahrq.gov/issue/unpacking-complexity-covid-19-fatalities-adverse-events-contributing-factors-single-center
January 25, 2023 - retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced … The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of
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psnet.ahrq.gov/issue/identifying-medication-errors-neonatal-intensive-care-units-two-center-study
November 11, 2020 - period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced … Preterm neonates experienced medication errors significantly more often than term neonates.
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psnet.ahrq.gov/issue/investigating-long-term-consequences-adverse-medical-events-among-older-adults
March 24, 2019 - multiple Medicare databases over a 7-year period, this study found that nearly 1 in 5 older adults experienced … Patients who experienced an adverse medical event had much higher mortality rates, though it should be
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-creative-strategies-lee.pdf
June 02, 2025 - Creative Ideas
Why organizations are starting with their staff:
►Close to patient care experiences
►Experienced … collaborative development of ideas
► Enlist influential staff to pursue idea implementation (e.g.,
experienced
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psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
October 15, 2014 - Pediatric patients younger than 2 years of age and intensive care unit patients experienced the highest … rate of errors, whereas neonatal patients experienced the lowest rate.
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psnet.ahrq.gov/node/40037/psn-pdf
September 20, 2011 - landmark
Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced … However, fewer than 2% of patients
experienced either a never event or a preventable complication for