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psnet.ahrq.gov/node/856641/psn-pdf
January 01, 2009 - WebAIRS Anesthesia Incident Reporting System. … https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system
Reporting errors in anesthesiology … This website
serves as a secure mechanism for submitting incident reports to a centralized system for … https://psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/node/43826/psn-pdf
June 01, 2015 - Radiation Oncology Incident Learning System. … https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
Reporting of near misses and … This Web
site supports an online portal facilitating incident reporting to enable data and experience … https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/node/74169/psn-pdf
December 08, 2021 - Blame is known to limit discussions of near-misses and failures, which negatively impacts learning and
incident … This article describes work to examine blameful context present in anesthesiology
incident documentation … https://psnet.ahrq.gov/issue/learn-not-blame
https://psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national-database
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psnet.ahrq.gov/node/39790/psn-pdf
March 21, 2017 - Integrating incident data from five reporting systems to
assess patient safety: making sense of the … Integrating incident data from five reporting systems to
assess patient safety: making sense of the … https://psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making … https://psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making-sense-elephant … https://psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making-sense-elephant
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psnet.ahrq.gov/node/40675/psn-pdf
November 28, 2016 - Patients' and family members' views on how clinicians
enact and how they should enact incident disclosure … Patients' and family members' views on how clinicians enact and how
they should enact incident disclosure … psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they-
should-enact-incident … psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they-should-enact-incident … psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they-should-enact-incident
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psnet.ahrq.gov/node/35876/psn-pdf
June 18, 2013 - External Inquiry into the adverse incident that occurred at
Queen's Medical Centre, Nottingham, 4th … https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham … https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham … -4th-january-2001
https://psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham
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psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event
April 10, 2019 - April 10, 2019
Psychological impact and recovery after involvement in a patient safety incident … Second victims among baccalaureate nursing students in the aftermath of a patient safety incident … 2021
Increased risk of burnout for physicians and nurses involved in a patient safety incident … study measuring the difference of healthcare workers reactions among those involved in a patent safety incident … September 19, 2016
What to do with healthcare incident reporting systems.
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psnet.ahrq.gov/issue/prescribers-perspectives-including-reason-use-information-prescriptions-and-medication-labels
July 14, 2021 - workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident … December 8, 2021
Evaluation of older persons' medications: a critical incident technique … The nature, severity and causes of medication incidents from an Australian community pharmacy incident … July 28, 2021
Medication incident recovery and prevention utilising an Australian community … pharmacy incident reporting system: the QUMwatch study.
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digital.ahrq.gov/ahrq-funded-projects/developing-passive-digital-marker-prediction-childhood-asthma-treatment
January 01, 2023 - Undertreatment of childhood asthma is prevalent, and often the right treatment for an initial diagnosis—the “incident … Two-thirds of incident childhood asthma cases continue to have persistent symptoms even after treatment … are as follows: Develop and evaluate the predictive performance of a PDM-TR among children with an incident … Eligible cases will include children up to age 11 who were born between 2005-2019 and have had incident … Researchers hypothesize that, when applied to risk and prognostic EHR data derived from incident asthma
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psnet.ahrq.gov/node/45560/psn-pdf
October 19, 2016 - Learning from excellence in healthcare: a new approach
to incident reporting. … Learning from excellence in healthcare: a new approach to incident reporting. … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
Learning … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/44736/psn-pdf
December 16, 2015 - Harms from discharge to primary care: mixed methods
analysis of incident reports. … Harms from discharge to primary care: mixed methods analysis of
incident reports. … https://psnet.ahrq.gov/issue/harms-discharge-primary-care-mixed-methods-analysis-incident-reports
Adverse … https://psnet.ahrq.gov/issue/harms-discharge-primary-care-mixed-methods-analysis-incident-reports
https
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psnet.ahrq.gov/node/44967/psn-pdf
March 16, 2016 - Wrong site surgery: a critical incident analysis of a near
miss.
March 16, 2016
Tichanow S. … Wrong site surgery: A critical incident analysis of a near miss. … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss
Despite efforts … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/836853/psn-pdf
April 06, 2022 - https://psnet.ahrq.gov/issue/use-e-triggers-identify-diagnostic-errors-paediatric-ed
Trigger tools and incident … study compared the performance of an electronic trigger tool plus manual
screening versus existing incident … the trigger tool and substantiated by manual review, less than 10% were identified
through existing incident
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psnet.ahrq.gov/node/47879/psn-pdf
June 05, 2019 - in the health care setting has been well described and is
one of the challenges in using data from incident … attitudes-nursing-students-and-clinical-instructors-towards-reporting-irregular-incidents
https://psnet.ahrq.gov/issue/problem-incident-reporting … https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm
https
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psnet.ahrq.gov/node/43960/psn-pdf
April 01, 2015 - Understanding the causes of intravenous medication
administration errors in hospitals: a qualitative critical
incident … Understanding the causes of intravenous medication administration
errors in hospitals: a qualitative critical incident … understanding-causes-intravenous-medication-administration-errors-hospitals-
qualitative
The critical incident … understanding-causes-intravenous-medication-administration-errors-hospitals-qualitative
https://psnet.ahrq.gov/issue/critical-incident-technique
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Checking for biases in incident reporting. In: Phimister JR, Bier VM, Kunreuther HC. … “The incident database will help identify improvement opportunities.” … Strategies to Improve Incident Reporting
Promote and sustain a culture of learning from mistakes
Make … factors, not to just create incident counts
Share the learning derived from incident analyses with … reporting system
More than 140,000 incident reports submitted in first 5 years
Success attributed
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psnet.ahrq.gov/node/61024/psn-pdf
October 14, 2020 - on long-term
care for people with intellectual disability: an interrupted
time series analysis of incident … term
care for people with intellectual disability: an interrupted time series analysis of incident reports … This study
compared incident reporting at one Dutch long-term care facility for people with intellectual
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psnet.ahrq.gov/node/47570/psn-pdf
December 05, 2018 - surveillance-and
Most health care organizations primarily rely on retrospective techniques such as incident … substantial
proportion of patient safety events and are not effective for real-time feedback or safety incident … //psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm … https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm
https … ://psnet.ahrq.gov/issue/problem-incident-reporting
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
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psnet.ahrq.gov/node/46294/psn-pdf
October 29, 2017 - reporting-perioperative-adverse-events-pediatric-anesthesiologists-tertiary-
childrens
Underreporting of adverse events is a known shortcoming of incident … to reporting and creating a local requirement
to complete adverse event reports using an electronic incident … The study team concluded
that mandated reporting addresses underuse of incident reporting systems. … reporting-perioperative-adverse-events-pediatric-anesthesiologists-tertiary-childrens
https://psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement
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psnet.ahrq.gov/issue/patients-and-family-members-experiences-open-disclosure-following-adverse-events
September 29, 2017 - Patients' and family members' views on how clinicians enact and how they should enact incident … June 14, 2011
What prevents incident disclosure, and what can be done to promote it? … October 21, 2011
Narrativizing errors of care: critical incident reporting in clinical … June 23, 2009
Practising open disclosure: clinical incident communication and systems … June 26, 2019
Communication and Resolution After an Adverse Health Care Incident.