-
psnet.ahrq.gov/issue/surgeons-must-tell-patients-double-booked-surgeries-new-guidelines-say
March 24, 2016 - associated with concurrent surgeries, reviews a previous news investigation into the practice, and includes
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psnet.ahrq.gov/issue/sorry-works-20-disclosure-apology-and-relationships-prevent-medical-malpractice-claims
November 30, 2007 - Version 2.0 includes a chapter focusing on the patient's role in effecitve post adverse event commuinication
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psnet.ahrq.gov/issue/human-error-medicine
July 06, 2011 - This book, published well in advance of the Institute of Medicine report To Err is Human , includes
-
psnet.ahrq.gov/issue/medication-related-adverse-outcomes-us-hospitals-and-emergency-departments-2008
September 15, 2010 - Utilization Project , this report updates a 2004 analysis of medication-related adverse events and includes
-
psnet.ahrq.gov/issue/what-every-health-care-organization-should-know-about-sentinel-events
November 27, 2018 - The text includes a sample sentinel event root cause analysis form and a glossary.
-
psnet.ahrq.gov/node/48016/psn-pdf
January 01, 2020 - Investigators
adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes
-
psnet.ahrq.gov/primer/responding-patient-safety-events
October 18, 2023 - Such communication includes key facts, results of the root cause analysis and other investigations into … highlights that disclosure is an ongoing process that starts with an initial conversation after an event and includes … Patients and families report that the content of disclosure that matters most to them includes an explanation
-
psnet.ahrq.gov/node/42149/psn-pdf
December 23, 2016 - The sentinel event database includes 98 alarm-related events (80 of which
resulted in death) between
-
psnet.ahrq.gov/node/44857/psn-pdf
March 23, 2016 - The report includes tools to related to the
recommendations.
-
psnet.ahrq.gov/node/39543/psn-pdf
May 19, 2010 - presents data from more than 300,000 respondents and greater than 800 hospitals nationwide, and
also includes
-
psnet.ahrq.gov/node/44951/psn-pdf
March 02, 2016 - Commission's Targeted Solutions Tool, an online application to improve handoff communication,
which includes
-
psnet.ahrq.gov/node/35906/psn-pdf
May 27, 2011 - Discussion includes
specific recommendations that resulted from the FMEA and presentation of the error
-
psnet.ahrq.gov/node/35448/psn-pdf
September 18, 2009 - Discussion includes detailed
analyses illustrating the relationships, or lack thereof, between the different
-
psnet.ahrq.gov/node/46624/psn-pdf
November 29, 2017 - physicians fail to empower
patients and recommend communication training for postgraduate physicians that includes
-
psnet.ahrq.gov/node/42917/psn-pdf
February 05, 2014 - The project also includes a report from physicians,
malpractice insurers, and policy experts translating
-
psnet.ahrq.gov/node/41940/psn-pdf
April 21, 2015 - This model includes full disclosure of adverse
events, appropriate investigations, implementation of
-
psnet.ahrq.gov/node/45067/psn-pdf
May 11, 2016 - The 2016 report includes data from 680 hospitals.
-
psnet.ahrq.gov/node/39396/psn-pdf
November 02, 2014 - The piece includes specific recommendations
for medical school and academic medical center leadership
-
psnet.ahrq.gov/node/36308/psn-pdf
January 05, 2017 - authors found a rate of 11.3 AEs per 1000 patient-days,
consistent with prior research, although this includes
-
psnet.ahrq.gov/node/35494/psn-pdf
May 27, 2011 - Discussion includes
analysis of the organizational and financial characteristics of participating hospitals