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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39583/psn-pdf
    October 30, 2010 - The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems … The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems … https://psnet.ahrq.gov/issue/harm-susceptibility-model-method-prioritise-risks-identified-patient-safety … reporting data to identify work areas with safety problems and rank the severity of safety problems identified … https://psnet.ahrq.gov/issue/harm-susceptibility-model-method-prioritise-risks-identified-patient-safety-reporting-systems
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44946/psn-pdf
    February 01, 2017 - Quality gaps identified through mortality review. … Quality gaps identified through mortality review. … https://psnet.ahrq.gov/issue/quality-gaps-identified-through-mortality-review Inpatient mortality represents … This study described the implementation of an institution-wide mortality review process, which identified … https://psnet.ahrq.gov/issue/quality-gaps-identified-through-mortality-review https://psnet.ahrq.gov/
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43095/psn-pdf
    April 09, 2014 - Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory … Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory … https://psnet.ahrq.gov/issue/intravenous-chemotherapy-preparation-errors-patient-safety-risks-identified … https://psnet.ahrq.gov/issue/intravenous-chemotherapy-preparation-errors-patient-safety-risks-identified-pan-canadian … https://psnet.ahrq.gov/issue/intravenous-chemotherapy-preparation-errors-patient-safety-risks-identified-pan-canadian
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37304/psn-pdf
    January 04, 2012 - Characteristics of patient care management problems identified in emergency department morbidity and … Characteristics of patient care management problems identified in emergency department morbidity and … https://psnet.ahrq.gov/issue/characteristics-patient-care-management-problems-identified-emergency- … https://psnet.ahrq.gov/issue/characteristics-patient-care-management-problems-identified-emergency-department-morbidity … https://psnet.ahrq.gov/issue/characteristics-patient-care-management-problems-identified-emergency-department-morbidity
  5. psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-serious-incident
    February 21, 2024 - Book/Report Retained Swabs Following Invasive Procedures: Themes Identified from … Citation Text: Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS … Citation Citation Text: Retained Swabs Following Invasive Procedures: Themes Identified
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44176/psn-pdf
    August 21, 2015 - Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative … Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative … https://psnet.ahrq.gov/issue/patient-and-carer-identified-factors-which-contribute-safety-incidents-primary … The investigators identified several unique themes related to safety, including difficulties in accessing … https://psnet.ahrq.gov/issue/patient-and-carer-identified-factors-which-contribute-safety-incidents-primary-care
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43412/psn-pdf
    May 28, 2015 - An observational study of how patients are identified before medication administrations in medical and … An observational study of how patients are identified before medication administrations in medical and … https://psnet.ahrq.gov/issue/observational-study-how-patients-are-identified-medication-administrations … https://psnet.ahrq.gov/issue/observational-study-how-patients-are-identified-medication-administrations-medical-and … https://psnet.ahrq.gov/issue/observational-study-how-patients-are-identified-medication-administrations-medical-and
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852698/psn-pdf
    August 30, 2023 - For electronic filtering of patient records, patients are electronically identified with the defined … A lack of screening was a significant issue identified in the eA process for AAA.1 Based on the eA/ … diagnostic errors are not routinely identified. … Since April 2022, many additional patients have been identified and managed. … follow-up until identified by the SureNet system.
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837768/psn-pdf
    August 03, 2022 - comparison-voluntary-safety-reporting-system-global-trigger-tool-identifying- adverse-events Adverse events can be identified … In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared … to 21 in the voluntary reporting system; only two AE were identified by both.
  10. psnet.ahrq.gov/issue/disparities-adverse-event-reporting-hospitalized-children
    July 27, 2022 - In this study, researchers compared rates of AE submitted to the VER against those identified using the … The GAPPS tool identified 37 AE in patients with limited English proficiency ; none of these were reported … August 3, 2022 Monitoring preventable adverse events and near misses: number and type identified
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60618/psn-pdf
    June 24, 2020 - Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause … Omission errors were commonly identified by all three methods, but identification of other errors varied … For example, incident reports most commonly identified wrong dose and wrong time errors.
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850165/psn-pdf
    June 07, 2023 - This study asked adolescent (ages 15-19) patient portal users if they had identified errors or omissions … Approximately one-quarter of patients identified an error and 20% identified an omission.
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61116/psn-pdf
    November 11, 2020 - medication containers during pharmacist transitional care visits and impact on medication discrepancies identified … medication containers during pharmacist transitional care visits and impact on medication discrepancies identified … However, when patients did present to their PCC visit with medication containers, pharmacists identified
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36544/psn-pdf
    July 14, 2010 - Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research … Targeted Chart Review of Pediatric Patient Safety Events Identified by the Agency for Healthcare Research … https://psnet.ahrq.gov/issue/targeted-chart-review-pediatric-patient-safety-events-identified-agency- … https://psnet.ahrq.gov/issue/targeted-chart-review-pediatric-patient-safety-events-identified-agency-healthcare-research … https://psnet.ahrq.gov/issue/targeted-chart-review-pediatric-patient-safety-events-identified-agency-healthcare-research
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840170/psn-pdf
    November 16, 2022 - 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.
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39431/psn-pdf
    April 07, 2010 - Identified safety risks with splitting and crushing oral medications. April 7, 2010 Paparella S. … Identified safety risks with splitting and crushing oral medications. … https://psnet.ahrq.gov/issue/identified-safety-risks-splitting-and-crushing-oral-medications In the … https://psnet.ahrq.gov/issue/identified-safety-risks-splitting-and-crushing-oral-medications https://
  17. psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
    December 18, 2019 - Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause … Omission errors were commonly identified by all three methods, but identification of other errors varied … For example, incident reports most commonly identified wrong dose and wrong time errors.
  18. psnet.ahrq.gov/issue/root-cause-analysis-using-prevention-and-recovery-information-system-monitoring-and-analysis
    May 18, 2022 - This review identified 25 studies that used the PRISMA method to analyze UEs. … provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified … June 16, 2021 Monitoring preventable adverse events and near misses: number and type identified
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44208/psn-pdf
    July 16, 2015 - Preventability of voluntarily reported or trigger tool–identified medication errors in a pediatric institution … Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in a Pediatric Institution … https://psnet.ahrq.gov/issue/preventability-voluntarily-reported-or-trigger-tool-identified-medication-errors … https://psnet.ahrq.gov/issue/preventability-voluntarily-reported-or-trigger-tool-identified-medication-errors-pediatric … https://psnet.ahrq.gov/issue/preventability-voluntarily-reported-or-trigger-tool-identified-medication-errors-pediatric
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39491/psn-pdf
    March 22, 2011 - The published literature on handoffs in hospitals: deficiencies identified in an extensive review. … The published literature on handoffs in hospitals: deficiencies identified in an extensive review. … https://psnet.ahrq.gov/issue/published-literature-handoffs-hospitals-deficiencies-identified-extensive-review … https://psnet.ahrq.gov/issue/published-literature-handoffs-hospitals-deficiencies-identified-extensive-review

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