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psnet.ahrq.gov/issue/use-medical-emergency-team-responses-reduce-hospital-cardiopulmonary-arrests
April 06, 2011 - The METs were comprised of critical care physicians and nurses and the retrospective study findings were … November 6, 2019
Findings of the first consensus conference on medical emergency teams … April 6, 2011
Implications of the failure to identify high-risk electrocardiogram findings
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psnet.ahrq.gov/issue/us-adoption-computerized-physician-order-entry-systems
April 24, 2018 - Using Leapfrog survey data derived from their efforts to reward CPOE adoption, investigators present findings … While many have argued that limitation in resources prevents wider implementation, these findings counter … Findings suggest that other factors, such as caring for the sickest patients or political interests in
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psnet.ahrq.gov/node/849604/psn-pdf
May 31, 2023 - Reducing errors resulting from commonly missed chest
radiography findings. … Reducing errors resulting from commonly missed chest radiography findings. … https://psnet.ahrq.gov/issue/reducing-errors-resulting-commonly-missed-chest-radiography-findings
Cognitive … https://psnet.ahrq.gov/issue/reducing-errors-resulting-commonly-missed-chest-radiography-findings
https
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psnet.ahrq.gov/node/42916/psn-pdf
February 05, 2014 - Are autopsy findings still relevant to the management of
critically ill patients in the modern era? … Are autopsy findings still relevant to the management of critically ill
patients in the modern era? … https://psnet.ahrq.gov/issue/are-autopsy-findings-still-relevant-management-critically-ill-patients-modern … -
era
This study used a blinded review of medical records matched with autopsy findings to examine … Clinical and postmortem
findings differed in 21% of cases, but only 2.4% had a discrepancy that may
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psnet.ahrq.gov/node/36224/psn-pdf
October 19, 2010 - Nonpunitive medication error reporting: 3-year findings
from one hospital's primum non nocere initiative … Nonpunitive medication error reporting: 3-year findings from one
hospital's Primum Non Nocere initiative … https://psnet.ahrq.gov/issue/nonpunitive-medication-error-reporting-3-year-findings-one-hospitals-primum … A comparison to post-initiative findings revealed that staff
perception of reporting improved after … https://psnet.ahrq.gov/issue/nonpunitive-medication-error-reporting-3-year-findings-one-hospitals-primum-non-nocere
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psnet.ahrq.gov/node/38589/psn-pdf
May 04, 2010 - Framing family conversation after early diagnosis of
iatrogenic injury and incidental findings. … Framing family conversation after early diagnosis of iatrogenic
injury and incidental findings. … psnet.ahrq.gov/issue/framing-family-conversation-after-early-diagnosis-iatrogenic-injury-and-
incidental-findings … psnet.ahrq.gov/issue/framing-family-conversation-after-early-diagnosis-iatrogenic-injury-and-incidental-findings … psnet.ahrq.gov/issue/framing-family-conversation-after-early-diagnosis-iatrogenic-injury-and-incidental-findings
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psnet.ahrq.gov/issue/ventilator-related-adverse-events-taxonomy-and-findings-3-incident-reporting-systems
March 01, 2017 - Study
Ventilator-related adverse events: a taxonomy and findings from 3 incident … Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems. … Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems.
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psnet.ahrq.gov/issue/finding-patient-patient-safety
November 17, 2014 - Commentary
Finding the patient in patient safety.
Citation Text:
Hor S-Y, Godbold N, Collier A, et al. Finding the patient in patient safety. Health (London). 2013;17(6):567-83. doi:10.1177/1363459312472082.
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DOI Google Scholar PubMed BibTeX EndNote X…
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psnet.ahrq.gov/node/46514/psn-pdf
October 18, 2017 - Comparison of clinical diagnoses and autopsy findings:
six-year retrospective study. … Comparison of clinical diagnoses and autopsy findings: six-year retrospective
study. … https://psnet.ahrq.gov/issue/comparison-clinical-diagnoses-and-autopsy-findings-six-year-retrospective … https://psnet.ahrq.gov/issue/comparison-clinical-diagnoses-and-autopsy-findings-six-year-retrospective-study … https://psnet.ahrq.gov/issue/clinical-diagnoses-and-autopsy-findings-discrepancies-critically-ill-patients
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psnet.ahrq.gov/issue/preventable-adverse-drug-events-causing-hospitalisation-identifying-root-causes-and
March 05, 2008 - The researchers used the study findings to develop learning messages for providers, patients, and families … March 5, 2008
Outpatient insulin-related adverse events due to mix-up errors: findings … Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings
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psnet.ahrq.gov/issue/evaluation-culture-safety-survey-clinicians-and-managers-academic-medical-center
September 28, 2010 - The authors share the differential findings among staff and leadership and outline how their findings … Key findings suggested a greater need for visibility among senior leadership to frontline staff and greater
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psnet.ahrq.gov/issue/acute-stroke-chameleons-university-hospital-risk-factors-circumstances-and-outcomes
March 05, 2025 - stroke, as was the case with patients who were in a coma or presented with atypical physical examination findings … March 6, 2005
Accuracy of emergency department clinical findings for diagnosis of coronavirus
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psnet.ahrq.gov/issue/disparities-racial-ethnic-and-payer-groups-pediatric-safety-events-us-hospitals
February 21, 2024 - The findings indicate that Black and Hispanic pediatric patients have a higher risk of safety events … Findings were similar when comparing patients with Medicaid versus private insurance.
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Group to develop communication best practices
for radiologists
– Within Minutes:
• Communicate findings … , or findings with increased risk of being
missed such as those that may not directly relate to clinical … and recommendations, and to receive
confirmation of receipt of findings
24
Systems Change Needed … Actionable Findings and the Role of IT Support: Report of the ACR Actionable Reporting Work
Group. … ACR Practice Parameters for Communication of Diagnostic Imaging Findings (Revised 2020).
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psnet.ahrq.gov/issue/performance-web-based-clinical-diagnosis-support-system-internists
August 02, 2023 - With key findings entered, the system suggested the correct diagnosis in 96% of cases. … View More
Related Resources
Cascades of care after incidental findings
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psnet.ahrq.gov/issue/interventions-promote-safety-culture-cancer-care-systematic-review
August 09, 2023 - This review summarizes findings from 18 articles on the topic of safety culture in radiation , medical … May 29, 2014
Safety hazards in cancer care: findings using three different methods.
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - to the primary care provider, or incorrect findings can be communicated.2 In a study from
one major … Findings that suggest a need for immediate or urgent intervention (as per ACR
guidelines) include: … and recommendations, and to receive confirmation of receipt of findings. … Actionable Findings and the Role of IT Support: Report of the
ACR Actionable Reporting Work Group. … ACR Practice Parameters for Communication of Diagnostic
Imaging Findings (Revised 2020).
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psnet.ahrq.gov/node/36751/psn-pdf
March 21, 2007 - Medmarx Data Report: A Chartbook of Medication-Error
Findings from the Perioperative Settings from 1998 … Patient Safety; 2006
https://psnet.ahrq.gov/issue/medmarx-data-report-chartbook-medication-error-findings-perioperative … -
settings-1998-2005
This report shares findings from analysis of more than 11,000 perioperative medication … https://psnet.ahrq.gov/issue/medmarx-data-report-chartbook-medication-error-findings-perioperative-settings … -1998-2005
https://psnet.ahrq.gov/issue/medmarx-data-report-chartbook-medication-error-findings-perioperative-settings
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psnet.ahrq.gov/node/39899/psn-pdf
October 06, 2010 - Comparison of the clinical diagnosis and subsequent
autopsy findings in medical malpractice. … Comparison of the clinical diagnosis and subsequent autopsy findings in
medical malpractice. … https://psnet.ahrq.gov/issue/comparison-clinical-diagnosis-and-subsequent-autopsy-findings-medical- … https://psnet.ahrq.gov/issue/comparison-clinical-diagnosis-and-subsequent-autopsy-findings-medical-malpractice … https://psnet.ahrq.gov/issue/comparison-clinical-diagnosis-and-subsequent-autopsy-findings-medical-malpractice
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psnet.ahrq.gov/node/42768/psn-pdf
November 27, 2013 - Findings and Lessons From the Improving Management
of Individuals With Complex Health Care Needs Through …
https://psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care … -
needs-through
This publication summarizes findings from 12 projects that explored how health information … https://psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care-needs-through … https://psnet.ahrq.gov/issue/findings-and-lessons-improving-management-individuals-complex-health-care-needs-through