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psnet.ahrq.gov/issue/building-simulation-based-crisis-resource-management-course-emergency-medicine-phase-1
September 26, 2016 - This survey of staff physicians, residents, and nurses identified substantial interest in crew resource … management training, and identified specific teamwork issues that could be addressed by such training
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psnet.ahrq.gov/issue/analysis-interprofessional-clinical-learning-environment-quality-improvement-and-patient
April 19, 2017 - The Clinical Learning Environment Review (CLER) program identified that resident involvement in interprofessional … facilitators, and barriers to resident involvement and a positive clinical learning environment were identified
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psnet.ahrq.gov/issue/do-healthcare-professionals-work-around-safety-standards-and-should-we-be-worried-scoping
December 21, 2016 - More than half of the identified studies focused on medication safety, such as workarounds related to … Organizational factors, including workload and time pressure, were identified in 93% of studies.
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psnet.ahrq.gov/issue/patient-carer-and-family-experiences-seeking-redress-and-reconciliation-following-life
April 24, 2018 - This systematic review identified 41 studies exploring the views of those affected by adverse events. … Four themes were identified: transparency , person-centeredness, trustworthiness, and restorative justice
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psnet.ahrq.gov/node/60323/psn-pdf
May 13, 2020 - The review identified 10 registered trials and 81 published non-
randomized trials. … studies reported that AI performance was comparable or
better than that of clinicians, the authors identified
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psnet.ahrq.gov/node/60228/psn-pdf
April 15, 2020 - From 2009-2018, 107 events were identified; nearly half of events involved MRI or
CT scanners and one-quarter … Nearly 75% of the identified events resulted in a delay in
care and 41% resulted in temporary harm (
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psnet.ahrq.gov/node/47787/psn-pdf
February 20, 2019 - Investigators identified a set of specific, evidence-based safety practices including standardization … They also identified a strong and consistent safety culture and
noted that structural conditions, such
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psnet.ahrq.gov/node/60176/psn-pdf
April 01, 2020 - Over 1,100 incident reports were identified; nearly half resulted in some
degree of harm but most (39% … The authors identified system priority action areas to mitigate harm among vulnerable
children, including
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psnet.ahrq.gov/node/39217/psn-pdf
January 20, 2010 - positive-predictive-value-ahrq-accidental-puncture-or-laceration-patient-safety-
indicator
The AHRQ Patient Safety Indicator accurately identified … accidental injuries due to medical care, but many
cases identified were clinically inconsequential.
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psnet.ahrq.gov/node/38404/psn-pdf
February 11, 2009 - health-care-professionals-views-about-safety-maternity-services-qualitative-
study
Maternity care professionals at all levels identified … a high level of concern about patient safety in obstetrics,
and identified improved staffing and teamwork
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psnet.ahrq.gov/innovation/predicting-dispensing-errors-community-pharmacies-application-systematic-human-error
February 06, 2019 - Observers conducted a Hierarchical Task Analysis (HTA) to identify tasks and sub-tasks, identified potential … dispensing errors, and then identified remedial solutions designed to avoid potential errors. … The analysis identified 88 potential errors and 35 remedial solutions.
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psnet.ahrq.gov/node/41287/psn-pdf
May 17, 2012 - psnet.ahrq.gov/issue/economic-evaluation-patient-safety-literature-review-methods
This systematic review identified … Of the studies identified, the
majority only characterized the cost of adverse events, and few formal
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psnet.ahrq.gov/node/60339/psn-pdf
May 20, 2020 - three-year period at one large, community hospital,
the program interviewed over 4,600 patients and identified … Of those, 66.5% identified harm associated with the incident and 61.9% had spoken to someone at
the
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psnet.ahrq.gov/node/42893/psn-pdf
March 13, 2014 - effect-patient-safety-strategies-incidence-adverse-events
https://psnet.ahrq.gov/issue/comparison-hospital-adverse-events-identified-three-widely-used-detection-methods … https://psnet.ahrq.gov/issue/comparison-hospital-adverse-events-identified-three-widely-used-detection-methods
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psnet.ahrq.gov/node/38757/psn-pdf
January 03, 2017 - Use of the PSI identified nearly all true DVT cases but also identified a significant
number of false
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psnet.ahrq.gov/node/37511/psn-pdf
February 06, 2008 - validity-retrospective-review-medical-records-means-identifying-adverse-
events-comparison
This study found that adverse events can be accurately identified … validity-retrospective-review-medical-records-means-identifying-adverse-events-comparison
https://psnet.ahrq.gov/issue/targeted-chart-review-pediatric-patient-safety-events-identified-agency-healthcare-research
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psnet.ahrq.gov/node/46976/psn-pdf
June 25, 2018 - psnet.ahrq.gov/issue/2017-update-pediatric-medical-overuse-review
Overuse of medical care has been identified … This review of literature published in 2017 identified 8 high-quality studies
documenting overuse of
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psnet.ahrq.gov/node/37965/psn-pdf
December 01, 2008 - building-simulation-based-crisis-resource-management-course-emergency-
medicine-phase-1
This survey of staff physicians, residents, and nurses identified … substantial interest in crew resource
management training, and identified specific teamwork issues
-
psnet.ahrq.gov/node/34981/psn-pdf
July 14, 2010 - discover factors that may contribute to a child’s risk for error during hospitalization, this study identified … These factors
contributed to nearly half of the identified patient safety problems.
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psnet.ahrq.gov/node/47648/psn-pdf
February 27, 2019 - Of the 285 adverse events identified during the
study period, 77.2% were captured by reporting systems … global-trigger-tool-shows-adverse-events-hospitals-may-be-ten-times-greater-previously
https://psnet.ahrq.gov/issue/comparison-hospital-adverse-events-identified-three-widely-used-detection-methods