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161. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. | PSNet
     psnet.ahrq.gov/issue/qualitative-content-analysis-retained-surgical-items-learning-root-cause-analysis
     December 06, 2023 - Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the … December 6, 2023 Characterising the nature of primary care patient safety incident reports … A content analysis of accreditation reports. … or alongside emergency departments: incorporating realist methodology into patient safety incident report … Diagnostic error in the emergency department: learning from national patient safety incident report

162. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/861773/psn-pdf
     January 31, 2024 - Hospital staff reports of coworker positive and unprofessional behaviours across eight hospitals: who … reports what about whom? … Hospital staff reports of coworker positive and unprofessional behaviours across eight hospitals: who … reports what about whom? … https://psnet.ahrq.gov/issue/hospital-staff-reports-coworker-positive-and-unprofessional-behaviours-across

163. Harnessing event report data to identify diagnostic error during the COVID-19 pandemic. | PSNet
     psnet.ahrq.gov/issue/harnessing-event-report-data-identify-diagnostic-error-during-covid-19-pandemic
     October 07, 2020 - Study Harnessing event report data to identify diagnostic error during the COVID- … Harnessing event report data to identify diagnostic error during the COVID-19 pandemic. … language processing, identified additional safety reports involving COVID-19 diagnostic errors and … Harnessing event report data to identify diagnostic error during the COVID-19 pandemic. … Defining diagnostic error: a scoping review to assess the impact of the National Academies' report

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865338/psn-pdf
     March 27, 2024 - Analysis of intervention employability in pharmacy- related medication safety reports at a tertiary … Analysis of intervention employability in pharmacy-related medication safety reports at a tertiary medical … Using 665 pharmacy-related medication safety reports at one hospital, researchers evaluated the actionability … of the reports on the ISMP hierarchy. … Three- quarters of the reports were only actionable at the least effective levels (e.g., suggestions

165. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. | PSNet
     psnet.ahrq.gov/issue/delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations
     March 25, 2020 - Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in … March 25, 2020 A review of adverse event reports from emergency departments in the Veterans … Defining diagnostic error: a scoping review to assess the impact of the National Academies' report … July 19, 2023 Using the Generic Analysis Method to analyze sentinel event reports across … July 15, 2020 A review of adverse event reports from emergency departments in the Veterans

166. What can we learn from coroners’ reports on preventable deaths? | PSNet
     psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths
     October 28, 2020 - Commentary What can we learn from coroners’ reports on preventable deaths? … What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. … What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. … January 4, 2021 Improving resident morning sign-out by use of daily events reports. … 2024 National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866814/psn-pdf
     September 25, 2024 - Accuracy of a proprietary large language model in labeling obstetric incident reports. … Accuracy of a proprietary large language model in labeling obstetric incident reports. … https://psnet.ahrq.gov/issue/accuracy-proprietary-large-language-model-labeling-obstetric-incident-reports … reporting is an important resource for identifying adverse events and near misses, but the volume of reports … https://psnet.ahrq.gov/issue/accuracy-proprietary-large-language-model-labeling-obstetric-incident-reports

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50775/psn-pdf
     January 01, 2021 - Content analysis of patient safety incident reports for older adult patient transfers, handovers, and … Content analysis of patient safety incident reports for older adult patient transfers, handovers, and … , cardiology, orthopedics and stroke to identify the types of transitions involved and whether reports … Half of all incident reports involved interunit/department/team transfers and the majority (69%) of … Few incident reports referenced individual or organizational learning (e.g., team discussions, root

169. Identifying health information technology usability issues contributing to medication errors across medication process stages. | PSNet
     psnet.ahrq.gov/issue/identifying-health-information-technology-usability-issues-contributing-medication-errors
     November 03, 2021 - This study reviewed 2,700 patient safety event reports to identify the type of medication error , the … Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports … 2021 A machine learning approach to reclassifying miscellaneous patient safety event reports … Using community detection techniques to identify themes in COVID-19-related patient safety event reports

170. Serious Reportable Events in Massachusetts. | PSNet
     psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
     May 03, 2023 - Book/Report Serious Reportable Events in Massachusetts. … Older reports are also available. … January 9, 2025 Patient Safety Authority Annual Reports. … April 30, 2024 National Healthcare Quality and Disparities Reports. … May 13, 2021 HANYS' Report on Report Cards.

171. Using patient safety reporting systems to understand the clinical learning environment: a content analysis. | PSNet
     psnet.ahrq.gov/issue/using-patient-safety-reporting-systems-understand-clinical-learning-environment-content
     June 19, 2024 - This qualitative study examined incident reports about surgical patients, comparing trainee reports … Trainees were more likely to enter reports anonymously and completed more elements for each report, but … they also used more blame language and submitted fewer reports overall.

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33571/psn-pdf
     March 15, 2025 - Initial reports often come from the frontline personnel directly involved in an event or the actions … key attributes: A supportive environment for event reporting that protects the privacy of staff who report … Reports are received from a broad range of personnel. … A structured mechanism is in place for reviewing reports and developing action plans. … Event reports are subject to selection bias due to their voluntary nature.

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867769/psn-pdf
     March 12, 2025 - Lessons from Event Reports. March 12, 2025 Lessons from Event Reports. Patient Safety Authority. … https://psnet.ahrq.gov/issue/lessons-event-reports Small successes can inform and motivate actions leading … This searchable collection of projects initiated in response to event reports supports the spread of … https://psnet.ahrq.gov/issue/lessons-event-reports https://psnet.ahrq.gov/issue/checklist https://psnet.ahrq.gov

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860722/psn-pdf
     January 17, 2024 - Ten years of incident reports on in-hospital cardiac arrest - Are they useful for improvements? … Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements? … https://psnet.ahrq.gov/issue/ten-years-incident-reports-hospital-cardiac-arrest-are-they-useful- improvements … This study reviewed and categorized incident reports regarding in-hospital cardiac arrest (IHCA) at two … Quarterly and annual tracking of reports allowed for prompt interventions such as implementation of

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866345/psn-pdf
     July 24, 2024 - Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports. … Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports. … https://psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2023-analysis-23970-reports … Based on reports submitted by long-term care facilities to the Pennsylvania Patient Safety Reporting … This continues the trend seen in the 2022 report.

176. A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. | PSNet
     psnet.ahrq.gov/issue/mixed-methods-analysis-patient-safety-incidents-involving-opioid-substitution-treatment
     August 25, 2021 - Using national data from England and Wales, this study analyzed 2,284 patient safety incident reports … or alongside emergency departments: incorporating realist methodology into patient safety incident report … September 26, 2018 Nature of blame in patient safety incident reports: mixed methods … December 9, 2020 Patient safety education 20 years after the Institute of Medicine report … March 18, 2020 ISMP medication error report analysis.

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866247/psn-pdf
     July 10, 2024 - Analysis of critical incident reports using natural language processing. … Analysis of critical incident reports using natural language processing. … https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using-natural-language-processing Natural … language processing (NLP) has been used to categorize patient safety reports and reduce the burden … https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using-natural-language-processing https

178. Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths | PSNet
     psnet.ahrq.gov/issue/using-who-international-classification-patient-safety-framework-identify-incident
     January 15, 2020 - The researchers took findings from coroner’s reports and classified those findings based on the ICPS. … Diagnostic error in the emergency department: learning from national patient safety incident report … or alongside emergency departments: incorporating realist methodology into patient safety incident report … November 11, 2020 Characterising the nature of primary care patient safety incident reports … Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports

179. Medicare failed to investigate suspicious infection cases from 96 hospitals. | PSNet
     psnet.ahrq.gov/issue/medicare-failed-investigate-suspicious-infection-cases-96-hospitals
     May 29, 2019 - This news article reports on an evaluation by the Office of Inspector General that found regulator review … of hospital-acquired infection reports submitted to Medicare to be insufficient, which hinders hospitals … Related report (PDF) Free full text Save Save to your library Print Download … Related Resources From the Same Author(s) FDA to end program that hid millions of reports … 2021 View More Related Resources Patient Safety Authority Annual Reports

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60730/psn-pdf
     January 01, 2021 - A machine learning approach to reclassifying miscellaneous patient safety event reports. … A machine learning approach to reclassifying miscellaneous patient safety event reports. … //psnet.ahrq.gov/issue/machine-learning-approach-reclassifying-miscellaneous-patient-safety-event- reports … positive user feedback on a machine learning approach to reclassifying “miscellaneous” patient safety reports … https://psnet.ahrq.gov/issue/machine-learning-approach-reclassifying-miscellaneous-patient-safety-event-reports