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  1. 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
  2. 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
  3. psnet.ahrq.gov/issue/sarasota-memorial-hospital-reviewed-after-restrained-patient-dies
    January 24, 2007 - This article reports on the death of a restrained patient and outlines the factors affecting the subsequent … Copy Citation Related Resources Adverse Health Events in Minnesota: Annual Reports … January 24, 2007 Report: hospital errors cost 18 lives.
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. psnet.ahrq.gov/issue/failing-grade-patient-safety
    March 14, 2007 - Twitter Linkedin Copy URL April 4, 2007 Times Colonist This article reports … February 29, 2012 National Healthcare Quality and Disparities Reports.
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. psnet.ahrq.gov/issue/preventing-cathetertubing-misconnections-much-needed-help-way
    May 07, 2018 - This piece describes reports of tubing misconnections and discusses upcoming standards for connectors … September 7, 2022 FDA to end program that hid millions of reports on faulty medical devices … July 3, 2014 ALERT: reports of severe harm after intravenous administration of breast
  16. psnet.ahrq.gov/issue/prescription-danger-medication-errors-inside-nursing-homes-lead-hospitalization-death
    August 27, 2014 - This news piece reports on risks associated with medication delivery in nursing homes and reveals several … December 5, 2012 In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48152/psn-pdf
    July 17, 2019 - Safety incident reports associated with blood transfusions. … Safety incident reports associated with blood transfusions. … https://psnet.ahrq.gov/issue/safety-incident-reports-associated-blood-transfusions This analysis of … transfusion-related safety incident reports found that such events were more commonly reported for pediatric … https://psnet.ahrq.gov/issue/safety-incident-reports-associated-blood-transfusions https://psnet.ahrq.gov
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836784/psn-pdf
    March 23, 2022 - Qualitative content analysis: a framework for the substantive review of hospital incident reports. … Qualitative content analysis: a framework for the substantive review of hospital incident reports. … /psnet.ahrq.gov/issue/qualitative-content-analysis-framework-substantive-review-hospital-incident- reports … This article discusses the need for a standardized approach to incident report analysis and how qualitative … ://psnet.ahrq.gov/issue/qualitative-content-analysis-framework-substantive-review-hospital-incident-reports
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867020/psn-pdf
    October 23, 2024 - What can we learn from coroners’ reports on preventable deaths? October 23, 2024 Jeraj S. … What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. … https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths Analysis of system … https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths https://psnet.ahrq.gov
  20. psnet.ahrq.gov/issue/consumer-guide-adverse-health-events
    June 04, 2024 - Book/Report Consumer Guide to Adverse Health Events. … This report provides background on the Minnesota Never Events reporting initiative , tips for patients … Related Resources From the Same Author(s) Adverse Health Events in Minnesota: Annual Reports … safety problems associated with information technology in general practice: an analysis of incident reports … June 4, 2024 Patient Safety Authority Annual Reports.

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