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psnet.ahrq.gov/node/45208/psn-pdf
April 22, 2017 - confusion rates in laboratory-based
memory and perception tests and corresponding error
rates in large … name confusion rates in laboratory-based memory and perception tests and corresponding
error rates in large … Eighty participants completed the tests and
their results were analyzed against actual errors in two large
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psnet.ahrq.gov/issue/routinely-recorded-patient-safety-events-primary-care-literature-review
April 18, 2012 - Despite large volumes of data generated in primary care settings, this literature review noted a paucity … A large, multicentre study.
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psnet.ahrq.gov/issue/what-expect-when-youre-evaluating-healthcare-improvement-concordat-approach-managing
February 17, 2011 - The authors illustrate how this process was used in a large-scale clinical system improvement initiative … A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.
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psnet.ahrq.gov/issue/missed-ischemic-stroke-diagnosis-emergency-department-emergency-medicine-and-neurology
August 03, 2017 - strokes were initially misdiagnosed in the emergency departments of an academic teaching hospital and a large … August 3, 2017
Targeting improvements in patient safety at a large academic center: an
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psnet.ahrq.gov/issue/overcoming-barriers-implementation-pharmacy-bar-code-scanning-system-medication-dispensing
October 25, 2010 - This case study reports on one large academic hospital's experience implementing a pharmacy bar code … A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large
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psnet.ahrq.gov/issue/framing-family-conversation-after-early-diagnosis-iatrogenic-injury-and-incidental-findings
November 14, 2011 - Most concerning, a large proportion of residents did not adequately describe potential complications … March 24, 2019
Medical large language models are vulnerable to data-poisoning attacks
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psnet.ahrq.gov/issue/project-boost-implementation-lessons-learned
August 21, 2013 - This qualitative study of a large-scale quality improvement effort to reduce readmissions and adverse … 2014
Assigning a team-based pager for on-call physicians reduces paging errors in a large
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psnet.ahrq.gov/issue/improved-outcomes-fewer-cesarean-deliveries-and-reduced-litigation-results-new-paradigm
November 27, 2012 - This article describes how one large, private health care system improved the safety of obstetric practice … systematic approach to the identification and classification of near-miss events on labor and delivery in a large
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psnet.ahrq.gov/issue/missed-opportunities-primary-care-management-early-acute-ischemic-heart-disease
January 08, 2016 - November 6, 2019
Intended and unintended effects of large-scale adverse event disclosure … : a controlled before-after analysis of five large-scale notifications. … October 19, 2022
From implementation to sustainment: a large-scale adverse event disclosure … August 18, 2021
Improving healthcare systems' disclosures of large-scale adverse events
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psnet.ahrq.gov/node/853436/psn-pdf
September 13, 2023 - This study examined I-PASS implementation practices over a six-year period in 10 departments at
one large … long-term-sustainability-and-adaptation-i-pass-handovers
https://psnet.ahrq.gov/primer/handoffs-and-signouts
https://psnet.ahrq.gov/issue/large-scale-implementation-i-pass-handover-system-academic-medical-centre
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psnet.ahrq.gov/issue/report-focuses-risk-patients-ed-errors
June 26, 2019 - June 26, 2019
Tiered daily huddles: the power of teamwork in managing large healthcare … patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large … Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large
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psnet.ahrq.gov/node/865922/psn-pdf
May 22, 2024 - improvement initiative to
increase compliance with intravenous smart pump drug
error reduction systems at a large … improvement initiative to increase
compliance with intravenous smart pump drug error reduction systems at a large
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psnet.ahrq.gov/node/866163/psn-pdf
June 19, 2024 - performance-evaluation-chatgpt-detecting-diagnostic-errors-and-their-
contributing-factors
ChatGPT and other large … performance-evaluation-chatgpt-detecting-diagnostic-errors-and-their-contributing-factors
https://psnet.ahrq.gov/issue/diagnostic-accuracy-large-language-model-pediatric-case-studies
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psnet.ahrq.gov/issue/morbidity-and-mortality-conference-pediatric-intensive-care-means-improving-patient-safety
December 16, 2009 - October 16, 2019
From implementation to sustainment: a large-scale adverse event disclosure … August 18, 2021
Intended and unintended effects of large-scale adverse event disclosure … : a controlled before-after analysis of five large-scale notifications. … November 3, 2015
Improving healthcare systems' disclosures of large-scale adverse events
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psnet.ahrq.gov/issue/introduction-rapid-response-system-united-states-veterans-affairs-hospital-reduced-cardiac
January 02, 2017 - December 2, 2014
From implementation to sustainment: a large-scale adverse event disclosure … August 18, 2021
Improving healthcare systems' disclosures of large-scale adverse events … March 26, 2015
Intended and unintended effects of large-scale adverse event disclosure … : a controlled before-after analysis of five large-scale notifications.
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psnet.ahrq.gov/issue/classifying-errors-preventable-and-potentially-preventable-trauma-deaths-9-year-review-using
November 27, 2012 - March 14, 2022
From implementation to sustainment: a large-scale adverse event disclosure … August 18, 2021
Improving healthcare systems' disclosures of large-scale adverse events … June 3, 2020
Medical large language models are vulnerable to data-poisoning attacks. … Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large
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psnet.ahrq.gov/issue/diagnostic-error-stroke-reasons-and-proposed-solutions
March 01, 2023 - patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large … March 1, 2023
WebM&M Cases
Missing a Large Vessel Occlusion … Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large
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psnet.ahrq.gov/issue/systemwide-strategy-embed-equity-patient-safety-event-analysis
November 16, 2022 - June 26, 2019
Medical large language models are vulnerable to data-poisoning attacks. … March 12, 2025
Large language model influence on diagnostic reasoning: a randomized clinical … July 3, 2016
Use of nondisclosure agreements in medical malpractice settlements by a large
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Large systems often have access to more resources in terms of funding, personnel, and information
technology … However, large health care systems also present challenges to the building and maintenance of safety … While there are advantages to scaling and sharing practices and data across a large network, safety … In a large complex organization, continual
reorganization and employee turnover occur. … In summary, while the development of large, integrated health care networks offer major opportunities
-
psnet.ahrq.gov/node/72669/psn-pdf
January 27, 2021 - nosocomial-transmission-and-outbreaks-coronavirus-disease-2019-need-
protect-both-patients-and
The large … need-protect-both-patients-and
https://psnet.ahrq.gov/issue/incidence-nosocomial-covid-19-patients-hospitalized-large-us-academic-medical-center