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psnet.ahrq.gov/issue/safety-events-impacting-hospitalized-patients-following-motor-vehicle-crashes-qualitative
October 07, 2020 - Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports … Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports … patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports … Analysis of incident reports from a patient safety organization. … or alongside emergency departments: incorporating realist methodology into patient safety incident report
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psnet.ahrq.gov/issue/patient-safety-palliative-care-mixed-methods-study-reports-national-database-serious
May 16, 2018 - Emerging Classic
Patient safety in palliative care: a mixed-methods study of reports … Patient safety in palliative care: A mixed-methods study of reports to a national database of serious … Patient safety in palliative care: A mixed-methods study of reports to a national database of serious … May 16, 2018
Characterising the nature of primary care patient safety incident reports … A content analysis of accreditation reports.
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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
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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)
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Patient Safety Authority Annual Reports
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psnet.ahrq.gov/issue/state-starts-project-track-serious-hospital-mistakes
May 10, 2006 - This article reports on the launch of Oregon's statewide voluntary incident reporting program to track … July 23, 2014
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient … Revised Report. … July 24, 2019
Teaching medical students to recognise and report errors. … February 16, 2022
Hospital Performance Report.
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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.
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psnet.ahrq.gov/issue/family-input-quality-and-safety-fiqs-using-mobile-technology-hospital-reporting-families-and
November 24, 2021 - Using a mobile health tool, pediatric patients and families were encouraged to report safety events … These reports were compared with incident reports (IRs) submitted to the internal incident reporting … Resources From the Same Author(s)
Patient and caregiver factors in ambulatory incident reports … Analysis of incident reports from a patient safety organization. … July 6, 2022
Differences in safety report event types submitted by graduate medical education
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psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-serious-incident
February 21, 2024 - Book/Report
Retained Swabs Following Invasive Procedures: Themes Identified from … a Review of NHS Serious Incident Reports. … Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports … This report examines reasons for 31 incidents of retained surgical swabs reported in the United Kingdom … Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports
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psnet.ahrq.gov/issue/how-well-do-we-communicate-comparison-intraoperative-diagnoses-listed-pathology-reports-and
May 29, 2019 - A comparison of intraoperative diagnoses listed in pathology reports and operative notes. … : a comparison of intraoperative diagnoses listed in pathology reports and operative notes. … : a comparison of intraoperative diagnoses listed in pathology reports and operative notes. … November 26, 2014
Computerized prescriber order entry–related patient safety reports: … September 6, 2023
Communicating certainty in pathology reports: interpretation differences
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psnet.ahrq.gov/issue/methodological-approaches-analyzing-medication-error-reports-patient-safety-reporting-systems
May 11, 2022 - Review
Methodological approaches for analyzing medication error reports in patient … Methodological approaches for analyzing medication error reports in patient safety reporting systems: … Methodological approaches for analyzing medication error reports in patient safety reporting systems: … calculation errors and other numeracy mishaps in hospitals: analysis of the nature and enablers of incident reports … Related Resources
Enhanced free-text search for aggregated medication error report
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psnet.ahrq.gov/issue/medication-errors-involving-overrides-healthcare-technology
January 11, 2017 - This article analyzes reports submitted to the Pennsylvania Patient Safety Authority to determine the … April 17, 2017
Wrong-patient medication errors: an analysis of event reports in Pennsylvania … Patient Safety 101
September 7, 2019
ISMP medication error report … safety problems associated with information technology in general practice: an analysis of incident reports
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psnet.ahrq.gov/issue/reporting-death-us-food-and-drug-administration-medical-device-adverse-event-reports
April 07, 2019 - Reporting of death in US Food and Drug Administration medical device adverse event reports … Reporting of death in US Food and Drug Administration medical device adverse event reports in categories … Reporting of death in US Food and Drug Administration medical device adverse event reports in categories … Resources
Artificial intelligence related safety issues associated with FDA medical device reports … The Report of the Independent Medicines and Medical Devices Safety Review.
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psnet.ahrq.gov/issue/nurses-improve-medication-safety-medication-allergy-and-adverse-drug-reports
October 19, 2022 - Commentary
Nurses improve medication safety with medication allergy and adverse drug reports … Nurses improve medication safety with medication allergy and adverse drug reports. … Nurses improve medication safety with medication allergy and adverse drug reports. … July 22, 2010
A safe haven for nurses to report medication errors?
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psnet.ahrq.gov/issue/stakeholder-safety-communication-patient-and-family-reports-safety-risks-hospitals
July 28, 2021 - Study
Stakeholder safety communication: patient and family reports on safety risks … Stakeholder safety communication: patient and family reports on safety risks in hospitals. … Stakeholder safety communication: patient and family reports on safety risks in hospitals. … the Same Author(s)
Getting the whole story: integrating patient complaints and staff reports
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psnet.ahrq.gov/issue/connecting-perspectives-quality-and-safety-patient-level-linkage-incident-adverse-event-and
April 28, 2021 - Safety events in hospitalized patients are captured in three ways: incident reports (process problems … ), adverse event reports (patient harm), and patient complaints . … Implications of electronic health record downtime: an analysis of patient safety event reports … May 10, 2017
Screening electronic health record–related patient safety reports using
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psnet.ahrq.gov/issue/does-error-and-adverse-event-reporting-physicians-and-nurses-differ
February 24, 2011 - Prior research has documented that physicians, in particular, do not file incident reports. … This evaluation of more than 260,000 incident reports from a broad cross-section of hospitals examined … events, similar to a prior study using the same incident reporting system, but physicians did tend to report … Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports … long-term care for people with intellectual disability: an interrupted time series analysis of incident reports
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psnet.ahrq.gov/issue/using-safety-ii-and-resilient-healthcare-principles-learn-never-events
February 20, 2019 - framework, the authors used a mixed-methods approach to retrospectively analyze root cause analysis (RCA) reports … low-to-moderate effectiveness, and that despite identifying systems challenges and weaknesses, many reports … vulnerabilities and opportunities for strengthening the RCA system and improving the quality of RCA reports … June 12, 2024
Adverse Health Events in Minnesota: Annual Reports.
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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
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psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national
December 16, 2015 - Book/Report
Characterising the nature of primary care patient safety incident reports … Characterising The Nature Of Primary Care Patient Safety Incident Reports In The England And Wales National … Characterising The Nature Of Primary Care Patient Safety Incident Reports In The England And Wales National … July 27, 2018
Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy … March 15, 2017
Report on the Safe Use of Pick Lists in Ambulatory Care Settings.
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psnet.ahrq.gov/issue/workforce-and-patient-safety
February 21, 2024 - Book/Report
Workforce and Patient Safety. … This collection of reports to be developed and distributed over the course of 2024 will cover workforce … Series information
Report 1: Temporary staff involvement in patient safety investigations
Report … Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports … December 4, 2024
Annual Speak Up Data Reports.