-
psnet.ahrq.gov/node/45391/psn-pdf
August 10, 2016 - https://psnet.ahrq.gov/issue/where-are-my-instruments-hazards-delivery-surgical-instruments
Insufficient
-
psnet.ahrq.gov/node/43171/psn-pdf
May 14, 2014 - These included errors of complacency, insufficient knowledge, and poor communication.
-
psnet.ahrq.gov/node/838238/psn-pdf
October 05, 2022 - Participating healthcare staff reported that
the program was easy to use and implement but noted that insufficient
-
psnet.ahrq.gov/node/47496/psn-pdf
June 15, 2019 - The most frequently noted
incident was decision to operate, followed by diagnostic error and insufficient
-
psnet.ahrq.gov/node/849329/psn-pdf
May 24, 2023 - issue/interorganizational-health-information-exchange-related-patient-safety-
incidents-descriptive
Insufficient
-
psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - SOE)
o ICU Admissions: Unclear impact on unplanned ICU admissions in both adults & children
(insufficient … o Modifying RRS can reduce mortality & arrest incidence in adults (low SOE); unclear in
children (insufficient … SOE)
o Serious adverse events related to RRS are infrequent in both adults & children
(insufficient … • Decreased opioid prescribing
Low
Healthcare
organization
guidelines
1 non-randomized study Insufficient … Peer comparison 1 RCT Insufficient
47
Barriers and Facilitators
Barriers
• Lack of training &
-
psnet.ahrq.gov/node/39428/psn-pdf
April 07, 2010 - human performance, equipment failure, resuscitation equipment not available, physical
environment, insufficient
-
psnet.ahrq.gov/node/44640/psn-pdf
February 20, 2016 - This commentary explores how insufficient implementation of
plan-do-study-act cycles can hinder its
-
psnet.ahrq.gov/node/44169/psn-pdf
November 06, 2015 - failures can contribute to patient harm—such as missed or delayed
diagnosis—and raises concerns about insufficient
-
psnet.ahrq.gov/node/46461/psn-pdf
November 01, 2017 - This review explores reasons clinicians remain
reluctant to disclose error, such as shame, insufficient
-
psnet.ahrq.gov/node/44113/psn-pdf
November 06, 2015 - These included an overall lack of a culture of safety, a cumbersome
reporting process, and insufficient
-
psnet.ahrq.gov/node/44854/psn-pdf
March 16, 2016 - previously considered an essential learning tool for clinicians, has decreased in
recent years due to insufficient
-
psnet.ahrq.gov/node/45789/psn-pdf
January 11, 2017 - concurrent surgeries has raised concerns about increased risks of surgeon
distraction, procedure delay, and insufficient
-
psnet.ahrq.gov/node/47393/psn-pdf
November 28, 2018 - still-failing-frail
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient
-
psnet.ahrq.gov/node/38463/psn-pdf
June 16, 2009 - study's findings raise concern about the current state of emergency care, most notably the presence of
insufficient
-
psnet.ahrq.gov/node/44620/psn-pdf
November 04, 2015 - https://psnet.ahrq.gov/issue/laboratory-testing-general-practice-patient-safety-blind-spot
Insufficient
-
psnet.ahrq.gov/node/44612/psn-pdf
October 28, 2015 - complacency about EHR usability problems, focus on billing
efficiency rather than clinical workflow, and insufficient
-
psnet.ahrq.gov/node/44161/psn-pdf
December 19, 2018 - The
authors explore how insufficient physician experience with mental illness in geriatric patients,
-
psnet.ahrq.gov/node/42890/psn-pdf
February 06, 2014 - These results suggest diagnostic errors are not
simply related to insufficient attention or time.
-
psnet.ahrq.gov/node/45251/psn-pdf
August 24, 2016 - a cataract surgery center, this news
article describes how factors such as production pressure and insufficient