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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38366/psn-pdf
    January 28, 2009 - Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes … Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes … and following up on reports. … , then developed a structured approach for addressing quality issues raised by the reports.  … This study, like most studies of data derived from incident reports, is limited because voluntary reports
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38375/psn-pdf
    December 01, 2019 - ISMP QuarterWatch Reports. April 17, 2019 Horsham, PA: Institute for Safe Medication Practices. … https://psnet.ahrq.gov/issue/ismp-quarterwatch-reports This website provides quarterly reports that … The report for the 2nd quarter of 2019 focuses on problems related to methotrexate errors, addictive … https://psnet.ahrq.gov/issue/ismp-quarterwatch-reports https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41098/psn-pdf
    March 04, 2015 - Automated identification of extreme-risk events in clinical incident reports. … Automated identification of extreme-risk events in clinical incident reports. … https://psnet.ahrq.gov/issue/automated-identification-extreme-risk-events-clinical-incident-reports … error reports is time intensive and often low yield. … This study reports on the use of informatics technology to screen incident reports in order to identify
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40460/psn-pdf
    April 30, 2024 - Patient Safety Authority Annual Reports. April 30, 2024 Pennsylvania Patient Safety Authority. … https://psnet.ahrq.gov/issue/patient-safety-authority-annual-reports This report summarizes patient … https://psnet.ahrq.gov/issue/patient-safety-authority-annual-reports https://psnet.ahrq.gov/issue/patient-safety-authority
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61037/psn-pdf
    January 01, 2021 - Analysis of incident reports from a patient safety organization. … Analysis of incident reports from a patient safety organization. … https://psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports … https://psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports-patient-safety … https://psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports-patient-safety
  6. psnet.ahrq.gov/issue/falls-english-and-welsh-hospitals-national-observational-study-based-retrospective-analysis
    June 15, 2011 - national observational study based on retrospective analysis of 12 months of patient safety incident reports … national observational study based on retrospective analysis of 12 months of patient safety incident reports … national observational study based on retrospective analysis of 12 months of patient safety incident reports … December 12, 2012 Semi-supervised classification of patient safety event reports.
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60893/psn-pdf
    January 01, 2021 - when-safety-event-reporting-seen-punitive-ive-been-psn-ed 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 … 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.  
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47921/psn-pdf
    June 18, 2019 - Using incident reports to assess communication failures and patient outcomes. … Using Incident Reports to Assess Communication Failures and Patient Outcomes. … https://psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes … Investigators examined incident reports at an academic medical center to characterize how communication … https://psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
  9. psnet.ahrq.gov/issue/drug-error-anaesthetic-practice-review-896-reports-australian-incident-monitoring-study
    June 13, 2011 - Study Drug error in anaesthetic practice: a review of 896 reports from the Australian … Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study … Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study … June 3, 2020 View More Related Resources ISMP medication error report
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47397/psn-pdf
    January 09, 2019 - using-patient-safety-reporting-systems-understand-clinical-learning- environment-content This qualitative study examined incident reports … about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses … 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.
  11. psnet.ahrq.gov/issue/nature-response-airway-management-incident-reports-high-income-countries-scoping-review
    December 15, 2014 - Review The nature of the response to airway management incident reports in high income … 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
  12. psnet.ahrq.gov/issue/assessment-automating-safety-surveillance-electronic-health-records-analysis-quality-and
    October 17, 2018 - October 17, 2018 Identifying health information technology related safety event reports … from patient safety event report databases. … Developing an evaluation strategy to assess large language models for patient safety event report analysis … Implications of electronic health record downtime: an analysis of patient safety event reports … March 1, 2017 Screening electronic health record–related patient safety reports using
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39470/psn-pdf
    January 09, 2024 - National Healthcare Quality and Disparities Reports. … https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-reports In this annual publication … , AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities … Report. … The 2023 report discusses the continued impact of COVID-19 on United States health care delivery.
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46391/psn-pdf
    February 08, 2018 - Nature of blame in patient safety incident reports: mixed methods analysis of a national database. … Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. … https://psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national … Researchers analyzed a sample of family practice patient safety incident reports from the England and … The authors suggest that successfully using incident reports to improve safety requires a shift to blame-free
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43566/psn-pdf
    December 19, 2014 - Bedside shift reports: what does the evidence say? … Bedside shift reports: what does the evidence say? … https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say Bedside shift reports may … https://psnet.ahrq.gov/issue/bedside-shift-reports-what-does-evidence-say https://psnet.ahrq.gov/issue … ://psnet.ahrq.gov/issue/bedside-shift-report-improves-patient-safety-and-nurse-accountability
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837671/psn-pdf
    July 13, 2022 - Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports. … Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports. … https://psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2021-analysis-17971-reports … https://psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2021-analysis-17971-reports
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73074/psn-pdf
    March 24, 2021 - In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star … https://psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and- … https://psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-rape-dont-dock-five … https://psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-rape-dont-dock-five
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34927/psn-pdf
    June 23, 2009 - Health Care Quality and Disparities: Lessons from the First National Reports. … from AHRQ's two inaugural reports, the 2003 National Healthcare Quality Report and the 2003 National … Healthcare Disparities Report (NHDR), are provided in this special issue.  … A review of initial findings from these reports is included.  … https://psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38692/psn-pdf
    March 04, 2015 - Errare humanum est: frequency of laterality errors in radiology reports. … Errare humanum est: frequency of laterality errors in radiology reports. … https://psnet.ahrq.gov/issue/errare-humanum-est-frequency-laterality-errors-radiology-reports Errors … Investigators reviewed more than 1 million reports at a single institution and discovered a very low … They were most common in "verbose" computed tomography (CT) and mammography reports with nearly 70%
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45502/psn-pdf
    March 01, 2017 - Screening electronic health record–related patient safety reports using machine learning. … Screening Electronic Health Record–Related Patient Safety Reports Using Machine Learning. … https://psnet.ahrq.gov/issue/screening-electronic-health-record-related-patient-safety-reports-using- … reporting systems are an important part of safety improvement programs, but difficulty in analyzing error reports … study described the development of a machine learning algorithm to analyze free-text data in incident reports

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