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161. 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

162. 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.

163. 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

164. 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

165. 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.

166. 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.

167. 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.

168. 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.

169. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. | PSNet
     psnet.ahrq.gov/issue/patient-safety-trends-2021-analysis-288882-serious-events-and-incidents-nations-largest-event
     May 19, 2021 - Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the … This study updates the 2020 report . … Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported … 2021 Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports … patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports

170. 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

171. 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

172. 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

173. 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

174. 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.

175. 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

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. 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

178. Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011. | PSNet
     psnet.ahrq.gov/issue/clinical-safety-englands-national-programme-it-retrospective-analysis-all-reported-safety
     December 31, 2014 - These results underscore the concerns in prior reports about the unintended consequences of implementing … Download Citation Related Resources From the Same Author(s) Using FDA reports … safety problems associated with information technology in general practice: an analysis of incident reports … January 7, 2015 Automated identification of extreme-risk events in clinical incident reports … safety problems associated with information technology in general practice: an analysis of incident reports

179. Identifying electronic health record usability and safety challenges in pediatric settings. | PSNet
     psnet.ahrq.gov/issue/identifying-electronic-health-record-usability-and-safety-challenges-pediatric-settings
     December 21, 2018 - Researchers examined 9000 safety event reports over a 5-year period from 3 pediatric health care facilities … October 17, 2018 Identifying health information technology related safety event reports … from patient safety event report databases. … Social determinants of health and patient safety: an analysis of patient safety event reports … May 13, 2020 A text mining approach to categorize patient safety event reports by medication

180. 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.