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161. Adverse-event-reporting practices by US hospitals: results of a national survey. | PSNet
     psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey
     December 30, 2014 - components of effective reporting systems were identified: a supportive environment for reporting, reports … received from a broad range of staff, timely dissemination of reports, and structured mechanisms to … review reports.  … hospitals have a safety culture that encourages reporting or promptly disseminate and analyze error reports … January 18, 2013 Semi-supervised classification of patient safety event reports.

162. Eliminating CLABSI: A National Patient Safety Imperative. | PSNet
     psnet.ahrq.gov/issue/eliminating-clabsi-national-patient-safety-imperative
     October 23, 2019 - Book/Report Eliminating CLABSI: A National Patient Safety Imperative. … This publication reports the impact hospital participation in CUSP had on patients. … 2016 View More Related Resources Patient Safety Authority Annual Reports … April 30, 2024 National Healthcare Quality and Disparities Reports. … May 1, 2015 Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative

163. When safety event reporting is seen as punitive: "I've been PSN-ed!" | PSNet
     psnet.ahrq.gov/issue/when-safety-event-reporting-seen-punitive-ive-been-psn-ed
     September 02, 2020 - This study characterized patient safety event report submissions over a six-month period at one university … health system and found that one-quarter of reports were  punitive .  … Compared to nonpunitive reports, punitive reports were more likely to focus on communication and employee … Punitive reports commonly involved adverse reactions or complications and communication errors.  

164. Analysis of reported drug interactions: a recipe for harm to patients. | PSNet
     psnet.ahrq.gov/issue/analysis-reported-drug-interactions-recipe-harm-patients
     January 20, 2016 - Drawing from reports of medication errors submitted over a 7-year period to the Pennsylvania Patient … April 17, 2017 Wrong-patient medication errors: an analysis of event reports in Pennsylvania … More Related Resources Wrong-patient medication errors: an analysis of event reports … September 7, 2016 Final Report of the Commission on Care.

165. More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA. | PSNet
     psnet.ahrq.gov/issue/more-algorithms-analysis-safety-events-involving-ml-enabled-medical-devices-reported-fda
     May 01, 2019 - This study utilizes adverse event reports submitted to the FDA 's Manufacturer and Use Facility Device … Mammography was implicated in 69% of reports, and the majority were near-miss events. … safety problems associated with information technology in general practice: an analysis of incident reports … Resources Artificial intelligence related safety issues associated with FDA medical device reports … Reporting of death in US Food and Drug Administration medical device adverse event reports

166. Accuracy of adverse-drug-event reports collected using an automated dispensing system. | PSNet
     psnet.ahrq.gov/issue/accuracy-adverse-drug-event-reports-collected-using-automated-dispensing-system
     April 06, 2022 - Study Accuracy of adverse-drug-event reports collected using an automated dispensing … Accuracy of adverse-drug-event reports collected using an automated dispensing system. … The authors evaluated the effectiveness and accuracy of using an automated dispensing system to report … Accuracy of adverse-drug-event reports collected using an automated dispensing system.

167. Physician specialty differences in unprofessional behaviors observed and reported by coworkers. | PSNet
     psnet.ahrq.gov/issue/physician-specialty-differences-unprofessional-behaviors-observed-and-reported-coworkers
     June 27, 2018 - In participating hospitals, staff can submit safety reports about coworkers demonstrating unprofessional … This study breaks down CORS reports by physician specialty (nonsurgeon nonproceduralists, emergency medicine … Less than 10% of all staff had 1 or more reports. … Surgeons had the highest percentage of physicians with at least one CORS report (13.8%) and nonsurgeon … June 27, 2018 Association of coworker reports about unprofessional behavior by surgeons

168. 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

169. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. | PSNet
     psnet.ahrq.gov/issue/stard-2015-guidelines-reporting-diagnostic-accuracy-studies-explanation-and-elaboration
     February 14, 2006 - Reporting Diagnostic Accuracy Studies (STARD), a checklist for researchers when writing diagnostic research … reports.

170. Classifying laboratory incident reports to identify problems that jeopardize patient safety. | PSNet
     psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety
     May 13, 2020 - Study Classifying laboratory incident reports to identify problems that jeopardize … Citation Text: Classifying laboratory incident reports to identify problems that jeopardize patient … Cite Citation Citation Text: Classifying laboratory incident reports … May 1, 2019 Report on the Safe Use of Pick Lists in Ambulatory Care Settings. … Revised Report.

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. NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. | PSNet
     psnet.ahrq.gov/issue/nhs-learning-deaths-reports-qualitative-and-quantitative-document-analysis-first-year
     February 22, 2023 - Study NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document … NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year … The National Health Service Secondary Care Trusts (NSCT) are required to report, learn from, and prevent … PubMed citation Free full text Related report Save Save to your library Print … July 13, 2022 Ockenden Report.

173. Patient reports of preventable problems and harms in primary health care. | PSNet
     psnet.ahrq.gov/issue/patient-reports-preventable-problems-and-harms-primary-health-care
     February 03, 2011 - Study Patient reports of preventable problems and harms in primary health care. … Patient reports of preventable problems and harms in primary health care. … Through interviews with patients, this AHRQ-funded study found that patients were more likely to report … Patient reports of preventable problems and harms in primary health care. … Related Resources From the Same Author(s) The Research on Adverse Drug Events and Reports

174. Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance. | PSNet
     psnet.ahrq.gov/issue/confidential-physician-feedback-reports-designing-optimal-impact-performance
     May 11, 2016 - Book/Report Confidential Physician Feedback Reports: Designing for Optimal Impact … Citation Text: Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance … Cite Citation Citation Text: Confidential Physician Feedback Reports … Final Report. … August 16, 2023 Final Report on Prioritization of Patient Safety Practices for a New

175. Evaluation of near-miss wrong-patient events in radiology reports. | PSNet
     psnet.ahrq.gov/issue/evaluation-near-miss-wrong-patient-events-radiology-reports
     June 13, 2015 - Study Evaluation of near-miss wrong-patient events in radiology reports. … JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. … JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. … August 28, 2019 ISMP medication error report analysis.

176. Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. | PSNet
     psnet.ahrq.gov/issue/comparing-process-and-outcome-oriented-approaches-voluntary-incident-reporting-two-hospitals
     June 15, 2011 - This study categorized more than 2200 incident reports into whether they described aberrant care processes … The authors advocate for hospitals to focus their IR systems on process-driven reports that encourage … January 16, 2008 Contributing factors identified by hospital incident report narratives … March 12, 2014 Semi-supervised classification of patient safety event reports. … January 7, 2009 Contributing factors identified by hospital incident report narratives

177. 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.

178. 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

179. 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

180. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. | PSNet
     psnet.ahrq.gov/issue/trends-healthcare-incident-reporting-and-relationship-safety-and-quality-data-acute-hospitals
     March 28, 2011 - However, using the number of incident reports filed as a metric of safety is not a proven relationship … This study examined hospital-based incident reports to the United Kingdom's  National Patient Safety … However, the authors also point out that increased incident reports failed to correlate with standardized … national observational study based on retrospective analysis of 12 months of patient safety incident reports … April 20, 2011 Relationship between tort claims and patient incident reports in the Veterans