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201. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854985/psn-pdf
     November 01, 2023 - A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient … A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient … https://psnet.ahrq.gov/issue/systematic-narrative-review-coroners-prevention-future-deaths-reports-pfds … In the UK, coroners may issue Prevention of Future Death reports (PFD) when they determine taking actions … https://psnet.ahrq.gov/issue/systematic-narrative-review-coroners-prevention-future-deaths-reports-pfds-tool-patient

202. 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

203. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60985/psn-pdf
     October 07, 2020 - Rapid-cycle improvement during the COVID-19 pandemic: using safety reports to inform incident command … Rapid-cycle improvement during the COVID-19 pandemic: using safety reports to inform incident command … https://psnet.ahrq.gov/issue/rapid-cycle-improvement-during-covid-19-pandemic-using-safety-reports- … describes the implementation of a new system for identifying, communicating, and resolving safety reports … https://psnet.ahrq.gov/issue/rapid-cycle-improvement-during-covid-19-pandemic-using-safety-reports-inform-incident-command

204. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867226/psn-pdf
     December 04, 2024 - The nature of the response to airway management incident reports in high income countries: a scoping … The nature of the response to airway management incident reports in high income countries: a scoping … https://psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries … https://psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries-scoping-review … https://psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries-scoping-review

205. Using Safety-II and resilient healthcare principles to learn from Never Events. | PSNet
     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.

206. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866315/psn-pdf
     July 17, 2024 - In participating hospitals, staff can submit safety reports about coworkers demonstrating unprofessional … This study breaks down CORS reports by physician specialty (nonsurgeon nonproceduralists, emergency … 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 … Pediatric nonsurgeon nonproceduralists had fewer reports compared to nonpediatric nonsurgeon nonproceduralists

207. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47949/psn-pdf
     July 10, 2019 - Association of coworker reports about unprofessional behavior by surgeons with surgical complications … Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications … Investigators sought to determine whether patients whose surgeons had coworker reports of unprofessional … Surgeons at two academic medical centers who had coworker reports of unprofessional behavior in the … These findings highlight the importance of empowering team members to report unprofessional behavior

208. Medication errors involving overrides of healthcare technology. | PSNet
     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 … a Tool for Improving Patient Safety March 29, 2023 ISMP medication error report … safety problems associated with information technology in general practice: an analysis of incident reports

209. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60053/psn-pdf
     January 01, 2021 - A review of adverse event reports from emergency departments in the Veterans Health Administration. … A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. … https://psnet.ahrq.gov/issue/review-adverse-event-reports-emergency-departments-veterans-health- administration … This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency … https://psnet.ahrq.gov/issue/review-adverse-event-reports-emergency-departments-veterans-health-administration

210. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60352/psn-pdf
     January 01, 2021 - Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality … Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality … https://psnet.ahrq.gov/issue/stakeholders-safety-patient-reports-unsafe-clinical-behaviors-distinguish … healthcare complaints) may differ from staff-generated information (derived from staff surveys and incident reports … https://psnet.ahrq.gov/issue/stakeholders-safety-patient-reports-unsafe-clinical-behaviors-distinguish-hospital-mortality

211. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73588/psn-pdf
     August 11, 2021 - 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 … psnet.ahrq.gov/issue/reporting-death-us-food-and-drug-administration-medical-device-adverse- event-reports … //psnet.ahrq.gov/issue/reporting-death-us-food-and-drug-administration-medical-device-adverse-event-reports … //psnet.ahrq.gov/issue/reporting-death-us-food-and-drug-administration-medical-device-adverse-event-reports

212. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73540/psn-pdf
     January 01, 2022 - Getting the whole story: integrating patient complaints and staff reports of unsafe care. … Getting the whole story: Integrating patient complaints and staff reports of unsafe care. … https://psnet.ahrq.gov/issue/getting-whole-story-integrating-patient-complaints-and-staff-reports-unsafe … - care This retrospective study linked patient complaint data with staff incident reports to better … https://psnet.ahrq.gov/issue/getting-whole-story-integrating-patient-complaints-and-staff-reports-unsafe-care

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853431/psn-pdf
     September 13, 2023 - Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. … Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. … https://psnet.ahrq.gov/issue/diagnostic-errors-uncommon-conditions-systematic-review-case-reports- diagnostic-errors … This article uses 560 case reports to classify contributing factors to diagnostic errors in rare conditions … https://psnet.ahrq.gov/issue/diagnostic-errors-uncommon-conditions-systematic-review-case-reports-diagnostic-errors

214. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/847535/psn-pdf
     April 12, 2023 - Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective … Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective … https://psnet.ahrq.gov/issue/using-generic-analysis-method-analyze-sentinel-event-reports-across- hospitals-retrospective … This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing … https://psnet.ahrq.gov/issue/using-generic-analysis-method-analyze-sentinel-event-reports-across-hospitals-retrospective

215. Insulin pumps have most reported problems in FDA database. | PSNet
     psnet.ahrq.gov/issue/insulin-pumps-have-most-reported-problems-fda-database
     October 03, 2018 - This news article reports on problems associated with ambulatory use of insulin pumps submitted to … AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report … Reporting of death in US Food and Drug Administration medical device adverse event reports … March 24, 2021 FDA to end program that hid millions of reports on faulty medical devices

216. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74109/psn-pdf
     November 24, 2021 - Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis. … Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis. … https://psnet.ahrq.gov/issue/patient-and-caregiver-factors-ambulatory-incident-reports-mixed-methods- … This mixed-methods analysis of ambulatory safety reports identified three themes related to patient … https://psnet.ahrq.gov/issue/patient-and-caregiver-factors-ambulatory-incident-reports-mixed-methods-analysis

217. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74205/psn-pdf
     January 01, 2022 - Communicating certainty in pathology reports: interpretation differences among staff pathologists, … Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians … https://psnet.ahrq.gov/issue/communicating-certainty-pathology-reports-interpretation-differences-among … clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports … https://psnet.ahrq.gov/issue/communicating-certainty-pathology-reports-interpretation-differences-among-staff-pathologists

218. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61066/psn-pdf
     October 28, 2020 - Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 … Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 … https://psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns … https://psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns-during-covid … -19 https://psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns-during-covid

219. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866908/psn-pdf
     October 09, 2024 - Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors … Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors … https://psnet.ahrq.gov/issue/risk-factors-wrong-site-surgery-study-1166-reports-informed-consent-and- … https://psnet.ahrq.gov/issue/risk-factors-wrong-site-surgery-study-1166-reports-informed-consent-and-schedule-errors … https://psnet.ahrq.gov/issue/risk-factors-wrong-site-surgery-study-1166-reports-informed-consent-and-schedule-errors

220. Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and
     June 23, 2021 - bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports … bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports … bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports … September 29, 2021 A review of adverse event reports from emergency departments in the … January 19, 2011 Errors in ABO labeling of deceased donor kidneys: case reports and approach