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psnet.ahrq.gov/issue/unsafe-care-residential-settings-older-adults-content-analysis-accreditation-reports
August 16, 2023 - Nearly 50% of incidents involved clinical processes or procedures, and 25% involved documentation errors
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psnet.ahrq.gov/issue/medication-adverse-events-ambulatory-setting-mixed-methods-analysis
October 21, 2020 - Anticoagulants , antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes … December 2, 2020
WebM&M Cases
Multiple Levels Involved
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psnet.ahrq.gov/issue/use-second-victim-experience-and-support-tool-svest-assess-impact-departmental-peer-support
December 23, 2020 - Providers involved in patient safety incidents can experience adverse psychological and physiological … March 13, 2024
Peer support and second victim programs for anesthesia professionals involved
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psnet.ahrq.gov/node/47948/psn-pdf
May 29, 2019 - potential-consequences-patient-complications-surgeon-well-being-systematic-
review
As many as half of all clinicians may be involved … health-care-professionals-second-victims-after-adverse-events-systematic-review
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/node/46052/psn-pdf
December 19, 2017 - issue/correlates-third-victim-phenomenon
A sentinel event affects patients, their families, clinicians involved … psnet.ahrq.gov/issue/sentinel-event-alert
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - All of the cases involved the nurse or EKG technician either entering the wrong medical
record number … One case involved a female infant whose treating physician received an electronic medical record (EMR … Fortunately, there were no adverse effects on any of the patients involved in the cases of mentioned … Despite this, incorrect EKG documentation can create unnecessary distress to all parties involved,
while … The nine cases of misidentified EKG results comprising this WebM&M issue all involved errors in patient
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psnet.ahrq.gov/issue/medication-related-malpractice-risks-2016-crico-strategies-national-cbs-report
July 18, 2018 - The majority of medication safety incidents involved primary care providers or hospital-based nurses … , and drugs commonly involved included analgesics, anticoagulants, and antibiotics.
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psnet.ahrq.gov/issue/cognitive-errors-and-logistical-breakdowns-contributing-missed-and-delayed-diagnoses-breast
March 02, 2011 - This study analyzed 56 missed or delayed cancer diagnoses and found that virtually all cases involved … cognitive errors and half involved logistical breakdowns .
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psnet.ahrq.gov/issue/second-victim-experiences-health-care-learners-and-influence-training-environment-postevent
January 31, 2024 - Clinicians involved in medical mistakes benefit from assistance to psychologically recover from the experience … September 21, 2022
Peer support and second victim programs for anesthesia professionals involved
-
psnet.ahrq.gov/node/43239/psn-pdf
June 11, 2014 - psnet.ahrq.gov/issue/cycle-redemption-medical-error-disclosure-and-apology-program
Clinicians who are involved … This commentary used interviews with physicians and
administrators involved in a hospital's disclosure
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psnet.ahrq.gov/node/43875/psn-pdf
September 19, 2016 - commit errors, acknowledging the
significant emotional impact that errors can have on the clinicians involved … implementation-second-victim-program-pediatric-hospital
https://psnet.ahrq.gov/issue/medical-error-second-victim
https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event
-
psnet.ahrq.gov/node/46272/psn-pdf
January 01, 2019 - Building on a previously described model, the institution developed a system to provide support
for staff involved … deployment-second-victim-peer-support-program-replication-study
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
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psnet.ahrq.gov/issue/duration-second-victim-symptoms-aftermath-patient-safety-incident-and-association-level
June 09, 2021 - Clinicians may experience distress after being involved in adverse events. … The authors call for organizations to provide support for clinicians involved in adverse events.
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psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
December 14, 2022 - transitions in geriatrics, cardiology, orthopedics and stroke to identify the types of transitions involved … Half of all incident reports involved interunit/department/team transfers and the majority (69%) of incidents
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psnet.ahrq.gov/node/46906/psn-pdf
May 30, 2018 - /issue/making-infusion-error-second-victims-infusion-therapy-related-medication-
errors
Providers involved … The authors of this survey study describe nursing graduates' experiences after being involved in
medication
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Hospital staff then offered confidential peer-to-peer support to the surgeon
and others involved in … At that
point, peer support for the involved clinicians should have been triggered and the family should … At least her point of contact (social worker/liaison),
the involved physician(s), a representative of … There should be no surprises for her or anyone else involved. … Often the meeting participants who were
involved in providing health care have things they feel are
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psnet.ahrq.gov/issue/promoting-psychological-well-being-healthcare-providers-facing-burden-adverse-events
February 15, 2023 - Clinicians involved in unexpected patient outcomes can experience negative emotions and frequently need … September 19, 2016
Supporting involved health care professionals (second victims) following
-
psnet.ahrq.gov/node/41454/psn-pdf
October 23, 2012 - diagnoses-breast
This study analyzed 56 missed or delayed cancer diagnoses and found that virtually all cases involved … cognitive errors and half involved logistical breakdowns.
-
psnet.ahrq.gov/node/46183/psn-pdf
July 12, 2017 - The majority of medication safety incidents involved primary care
providers or hospital-based nurses … , and drugs commonly involved included analgesics, anticoagulants, and
antibiotics.
-
psnet.ahrq.gov/node/45854/psn-pdf
July 12, 2017 - that was designed to provide
information about the second victim phenomenon and help support those involved … second-victim-phenomenon-after-clinical-error-design-and-evaluation-website-reduce-caregivers
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events