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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33584/psn-pdfMarch 15, 2025 - communication issues are the most common root cause of sentinel events (serious and preventable patient harm incidents -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33566/psn-pdfSeptember 15, 2024 - Debriefing and providing feedback, especially after critical incidents, are essential components of -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45036/psn-pdfFebruary 15, 2017 - Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. February 15, 2017 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110. https://psnet.ahrq.gov/issue/adverse-events-rehabilitation-… -
www.ahrq.gov/npsd/data/dashboard/info.htmlJune 01, 2019 - Dashboard Information NPSD Dashboards display data that follow the Common Formats for Event Reporting – Hospital Version (CFER-H) definitions of Adverse Events, i.e., the Common Formats Event Descriptions. There are 10 CFER-H modules: one Generic module applies to all reported events, and nine event-specific mo…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/851196/psn-pdfJuly 05, 2023 - Patient falls while under supervision: trends from incident reporting. July 5, 2023 Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs. 2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508. https://psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/41415/psn-pdfMay 30, 2012 - Hope modified the association between distress and incidence of self-perceived medical errors among practicing physicians: prospective cohort study. May 30, 2012 Hayashino Y, Utsugi-Ozaki M, Feldman MD, et al. Hope modified the association between distress and incidence of self-perceived medical errors among pract… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38766/psn-pdfNovember 14, 2011 - Incident reporting practices in the preanalytical phase: low reported frequencies in the primary health care setting. November 14, 2011 Söderberg J, Grankvist K, Brulin C, et al. Incident reporting practices in the preanalytical phase: Low reported frequencies in the primary health care setting. Scand J Clin Lab I… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37996/psn-pdfAugust 20, 2008 - "Every error counts": a web-based incident reporting and learning system for general practice. August 20, 2008 Hoffmann B, Beyer M, Rohe J, et al. "Every error counts": a web-based incident reporting and learning system for general practice. Qual Saf Health Care. 2008;17(4):307-12. doi:10.1136/qshc.2006.018440. ht… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44003/psn-pdfJune 17, 2015 - Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial. June 17, 2015 Verbakel NJ, Langelaan M, Verheij TJM, et al. Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial. Br J Gen Pract. 20… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44858/psn-pdfFebruary 10, 2016 - Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. February 10, 2016 Schulz CM, Krautheim V, Hackemann A, et al. Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. BMC Anesthesiol. 2016;16:4. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40803/psn-pdfOctober 31, 2011 - Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. October 31, 2011 van Walraven C, Jennings A, Taljaard M, et al. Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions. Can Med Assoc J. 2011;183(14). doi:1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38499/psn-pdfMarch 01, 2011 - The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. March 1, 2011 Cravero JP, Beach ML, Blike G, et al. The incidence and nature of adverse events during pediatric sedatio… -
psnet.ahrq.gov/issue/adverse-events-hospitals-medicares-responses-alleged-serious-eventsFebruary 18, 2009 - Government Resource Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. Citation Text: Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspecto…
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psnet.ahrq.gov/issue/how-effective-are-incident-reporting-systems-improving-patient-safety-systematic-literatureJanuary 18, 2023 - Review How effective are incident-reporting systems for improving patient safety? A systematic literature review. Citation Text: How effective are incident-reporting systems for improving patient safety? A systematic literature review. Stavropoulou C, Doherty C, Tosey P. Milbank Q. 2015;…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43006/psn-pdfApril 02, 2014 - Hamilton Acute Pain Service Safety Study: using root cause analysis to reduce the incidence of adverse events. April 2, 2014 Paul JE, Buckley N, McLean RF, et al. Hamilton acute pain service safety study: using root cause analysis to reduce the incidence of adverse events. Anesthesiology. 2014;120(1):97-109. doi:1… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74083/psn-pdfNovember 17, 2021 - Novel telephone-based interactive voice response system for incident reporting. November 17, 2021 McNiven B, Brown AD. Novel telephone-based interactive voice response system for incident reporting. Jt Comm J Qual Patient Saf. 2021;47(12):809-813. doi:10.1016/j.jcjq.2021.09.010. https://psnet.ahrq.gov/issue/novel-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/34812/psn-pdfMarch 05, 2008 - The critical incident technique. March 5, 2008 FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358. https://psnet.ahrq.gov/issue/critical-incident-technique This review details the background of a methodology aimed to record specific behaviors, rather than opinions or estimates, in evalu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/844791/psn-pdfSeptember 18, 2019 - Review of alternatives to root cause analysis: developing a robust system for incident report analysis. September 18, 2019 Hagley G, Mills PD, Watts B, et al. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019;8(3):e000646. doi:10.1136/bmjoq-2… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/39479/psn-pdfJanuary 20, 2011 - A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. January 20, 2011 Regenbogen SE, Hirose M, Imanaka Y, et al. A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. Qual Saf Health Care. 2010;19(6):e10. doi:10.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33935/psn-pdfFebruary 05, 2018 - The incidence and severity of adverse events affecting patients after discharge from the hospital. February 5, 2018 Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7. https://psnet.ahrq.gov/…
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