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161. Can we rely on patients' reports of adverse events? | PSNet
     psnet.ahrq.gov/issue/can-we-rely-patients-reports-adverse-events
     December 29, 2014 - Study Classic Can we rely on patients' reports of adverse … Can we rely on patients' reports of adverse events? … Can we rely on patients' reports of adverse events?

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. 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. 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

165. 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

166. 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.

167. 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

168. 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

169. 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.

170. 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

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. The Research on Adverse Drug Events and Reports (RADAR) project. | PSNet
     psnet.ahrq.gov/issue/research-adverse-drug-events-and-reports-radar-project
     October 19, 2022 - Study The Research on Adverse Drug Events and Reports (RADAR) project. … The Research on Adverse Drug Events and Reports (RADAR) project. JAMA. 2005;293(17):2131-40. … The Research on Adverse Drug Events and Reports (RADAR) project. JAMA. 2005;293(17):2131-40.

173. 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.

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60318/psn-pdf
     January 01, 2022 - Social determinants of health and patient safety: an analysis of patient safety event reports related … Social determinants of health and patient safety: an analysis of patient safety event reports related … language barriers contribute to patient safety events, the authors analyzed near- miss and adverse event reports … Of 1,553 included reports, 13% were likely or plausibly related to a patient’s language barrier. … The most common strategy for preventing future events cited in these reports involved use of interpreter

175. 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

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/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

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. Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency. | PSNet
     psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports-uk-national
     March 12, 2025 - Patient safety incidents associated with airway devices in critical care: a review of reports … Patient safety incidents associated with airway devices in critical care: a review of reports to the … The report makes recommendations for the proper use of monitoring equipment to ensure safety for intubated … Patient safety incidents associated with airway devices in critical care: a review of reports to the … June 27, 2018 Association of coworker reports about unprofessional behavior by surgeons