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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Classifying safety events related to diagnostic imaging from a safety reporting system using a human
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Reporting and Systems No CBC was obtained on admission. A lower segment hysterotomy was considered.
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - One systematic review of this topic identified several studies reporting improved technical performance
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - start of rounds, increased from 18.2% preintervention to 37.7% postintervention (p=0.03). 4 Parent reporting
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - National Coordinating Council for Medication Error Reporting. “Taxonomy of Medication Errors”.
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - the Partnership for Quality Measurement (PQM) and recently adopted for Hospital Inpatient Quality Reporting
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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - recommendations to reduce introducing bias into the data model, the authors stress the importance of standardized reporting
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - May 8, 2024
Quality and reporting of large-scale improvement programmes: a review of
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - However, analysis of the FDA Adverse Event Reporting System (FAERS) by Blau and colleagues suggested
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - department manager would be notified of the event and a report entered into the hospital's incident reporting
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Alternatively, the clinical laboratory may withhold reporting of lab results affected by hemolysis.
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - breast-milk errors continued to occur.( 5 ) Another study noted that critical incident monitoring resulted in reporting
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - the bundle for all of their ICU units (role-based training by discipline); (2) continuous compliance
reporting
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - Author(s)
Defining patient safety in hospice: principles to guide measurement and public reporting
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - start of rounds, increased from 18.2% preintervention to 37.7% postintervention (p=0.03).4
Parent reporting
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - to Improve Diagnosis, am the Vice Chair for the National Coordinating Counsel for Medication Error Reporting
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psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safety-final-report
September 06, 2011 - Book/Report
Classic
Improving Diagnostic Quality and Safety Final Report.
Citation Text:
Improving Diagnostic Quality and Safety Final Report. Washington, DC: National Quality Forum. September 19, 2017.
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psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder
April 17, 2019 - Commentary
Case report of a medication error: in the eye of the beholder.
Citation Text:
Naunton M, Nor K, Bartholomaeus A, et al. Case report of a medication error. Medicine (Baltimore). 2016;95(28):e4186. doi:10.1097/md.0000000000004186.
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psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
September 02, 2014 - Book/Report
Fluorouracil Incident Root Cause Analysis Report.
Citation Text:
Fluorouracil Incident Root Cause Analysis Report. Toronto, CA: Institute for Safe Medication Practices Canada; May 2007.
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psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
August 04, 2021 - Commentary
User's manual for the IOM's 'Quality Chasm' report.
Citation Text:
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
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