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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - But if you were the involved clinician, how would you want to be made aware? … In the present case, Reason's algorithm may define the error as blameless if the involved clinician acted … However, if the involved professional had a history of unsafe acts, the algorithm recognizes the need … If this occurred in the appropriate culture of patient safety, it would be expected that the involved … At this level, an authority figure may direct the involved professional to participate in a practice
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www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
August 01, 2022 - None of the discrepancies involved permanent disability or death, but almost half of the discrepancies … involved symptoms or temporary disability, of which 16 percent were judged to require an office visit … Cases involved discharge from one of four hospital sites affiliated with the academic medical center. … Notably, almost half (299 of 632) of reported near misses involved office processes. … In the first part of the study, researchers surveyed patients and medical staff involved in 41 claims
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www.ahrq.gov/patient-safety/reports/liability/neumiller.html
August 01, 2017 - Medication classes most commonly involved in potential ADEs are displayed in Table 1. … Medication discrepancies determined to contribute to serious potential ADEs involved the antineoplastic … Potential ADEs ascribed a significant rating often involved opioids, antihypertensives, anticoagulants … Medications commonly involved in discrepancies assessed to have insignificant consequences involved acetaminophen … The involved medicines were anticoagulants or antiplatelets (e.g., enoxaparin, warfarin, dipyridamole
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/164-cusp-meeting-pre-work.docx
June 02, 2025 - There are many ways to keep the Senior Executive involved with your CUSP team and with your unit. … Also, invite the Senior Executive to visit the unit or to attend Executive Walk Rounds to keep them involved
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psnet.ahrq.gov/node/45009/psn-pdf
March 30, 2016 - https://psnet.ahrq.gov/issue/fatal-mistakes
Health professionals involved in medical errors experience … psnet.ahrq.gov/issue/medical-error-second-victim
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … suffering-silence-qualitative-study-second-victims-adverse-events
https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event
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psnet.ahrq.gov/node/44645/psn-pdf
July 01, 2017 - post-traumatic-stress-disorder-amongst-surgical-trainees-unrecognised-risk
Physicians who experience adverse effects after being involved … post-traumatic-stress-disorder-amongst-surgical-trainees-unrecognised-risk
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … 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
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Healthcare workers involved in a medical
error or adverse event may experience a range of emotional … Healthcare staff involved in an adverse event can develop post-traumatic stress disorder (PTSD) with … Staff who are involved in continual system failures may
want to avoid bringing attention to more problems … Counteract Burnout
Addressing burnout is paramount to ensuring support for healthcare workers involved … Editor’s Note: Many resources refer to healthcare workers involved in a medical error as the “second
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Johnson.pdf
January 01, 2004 - patient safety considerations are incorporated into medical
device purchasing decisions, individuals involved … First, individuals
involved in the purchasing decisions were questioned using a structured interview … All
subjects were involved, albeit to different extents, in the latest purchase of
infusion pumps at … Those directly involved in the decisions at Sites 1 and
2 felt the best decision was made. … This indicated
some awareness of the human factors issues involved with device use safety.
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/choosing/index.html
June 01, 2020 - and usefulness of quality measurement activities without overly taxing the resources of all parties involved … Factors to Consider
Many factors are involved in choosing which quality measures to use, whatever the … If only one entity is involved, almost any quality measure can be used, provided that a rigorous and … If multiple entities are involved, the use of measures with rigorous and precise specifications is more
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cdsic.ahrq.gov/cdsic/cdsic-operations-center-charter
April 30, 2022 - and Coordinating CDS
Resources
News
CDSiC Leadership Viewpoints
Get Involved … Constraints and potential challenges related to Operations Center activities
Relevant stakeholders who are involved … GET INVOLVED IN CDSiC BY:
Signing up for the CDSiC Insider newsletter
Expressing interest … joining a CDSiC Workgroup
Sharing your feedback and/or questions with the CDSiC team
Get Involved
-
cdsic.ahrq.gov/cdsic/innovation-center-charter-bp
April 30, 2022 - and Coordinating CDS
Resources
News
CDSiC Leadership Viewpoints
Get Involved … Constraints and potential challenges related to Innovation Center activities
Relevant stakeholders who are involved … GET INVOLVED IN CDSiC BY:
Signing up for the CDSiC Insider newsletter
Expressing interest … joining a CDSiC Workgroup
Sharing your feedback and/or questions with the CDSiC team
Get Involved
-
cdsic.ahrq.gov/cdsic/stakeholder-community-outreach-center-charter
April 30, 2022 - and Coordinating CDS
Resources
News
CDSiC Leadership Viewpoints
Get Involved … Constraints and potential challenges related to Stakeholder Center activities
Relevant stakeholders who are involved … GET INVOLVED IN CDSiC BY:
Signing up for the CDSiC Insider newsletter
Expressing interest … joining a CDSiC Workgroup
Sharing your feedback and/or questions with the CDSiC team
Get Involved
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/pbrn/pbrn-irb-tipsheet.pdf
June 27, 2025 - Most efforts are not considered research and are not subject
to the HHS protection of human-involved … the PBRN leading the research project will use its IRB as the single IRB for all
clinical practices involved … When large health institutions are involved, additional research approval
steps may be required … serve as the single
IRB site and communicate with recruited clinical sites and
academic intuitions involved
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/choosing/choosing.doc
June 02, 2025 - and usefulness of quality measurement activities without overly taxing the resources of all parties involved … Return to Contents
Factors to Consider
Many factors are involved in choosing which quality measures … If only one entity is involved, almost any quality measure can be used, provided that a rigorous and … If multiple entities are involved, the use of measures with rigorous and precise specifications is more
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psnet.ahrq.gov/issue/impact-perioperative-catastrophes-anesthesiologists-results-national-survey
August 27, 2009 - The term " second victim " was coined to describe clinicians who are involved in medical errors, acknowledging … This study surveyed anesthesiologists and found that 84% of respondents were involved in at least one … that support providers at the time of the event and thereafter to help manage the emotional burden involved
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www.ahrq.gov/talkingquality/plan/environment.html
June 01, 2016 - It can be helpful to document what you know about them so that everyone involved is clear on who will … Questions about purchasers and regulators:
Among health care purchasers, who (if anyone) is most involved … Is a State agency or other regulatory body involved in quality measurement and reporting in your marketplace … Do you have the expertise in-house for all of the steps involved in effective reporting?
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cdsic.ahrq.gov/cdsic/year3-period-performance-report
September 30, 2024 - and Coordinating CDS
Resources
News
CDSiC Leadership Viewpoints
Get Involved … GET INVOLVED IN CDSiC BY:
Signing up for the CDSiC Insider newsletter
Expressing interest … joining a CDSiC Workgroup
Sharing your feedback and/or questions with the CDSiC team
Get Involved
-
psnet.ahrq.gov/node/46772/psn-pdf
March 04, 2019 - case-second-victim-support-program-pediatrics-successes-and-challenges-
implementation
After being involved … psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event … https://psnet.ahrq.gov/issue/supporting-involved-health-care-professionals-second-victims-following-adverse-health-event
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psnet.ahrq.gov/node/44316/psn-pdf
March 20, 2017 - how a second
victim intervention program participating with a PSO can provide support for clinicians involved … new-patient-safety-organizations-lower-roadblocks-medical-error-reporting
https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events … https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
https
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/shadowing.doc
June 02, 2025 - · All staff involved in the delivery of patient care in units with poor Safety Attitude Questionnaire … What happened during the shadowing exercise that involved multiple practice domains? … Did the providers involved seek help from a supervisor?
Yes
No
N/A
6.