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361. ABCDEF Bundle Data Literacy Training, Performance Measurement Tracking, and Performance Feedback | PSNet
     psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
     September 23, 2024 - Data algorithms for accurate and timely dashboards, and performance metrics reports in alignment with … and their ability to read or interpret performance reports. … It fosters performance data report comprehension in about 15 minutes in day-to-day casual conversation … Data algorithms for accurate and timely dashboards, and performance metrics reports in alignment with … Both IT and clinical staff should share a common understanding of needed EHR fields, and report outputs

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37906/psn-pdf
     July 16, 2008 - Medication-related patient safety incidents in critical care: a review of reports to the UK National … Medication-related patient safety incidents in critical care: a review of reports to the UK National … https://psnet.ahrq.gov/issue/medication-related-patient-safety-incidents-critical-care-review-reports-uk … https://psnet.ahrq.gov/issue/medication-related-patient-safety-incidents-critical-care-review-reports-uk-national-patient … https://psnet.ahrq.gov/issue/medication-related-patient-safety-incidents-critical-care-review-reports-uk-national-patient

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867845/psn-pdf
     February 26, 2025 - John Bender and Steve Kulju, two members of the NCPS team, report that NCPS piloted CPRA in 2020 using … failure mode of the model to sort the data from the proactive risk assessments and patient safety report … analyzed together, there were a total of 32 unique failure modes.2 Finally, the team analyzed the safety report … topic (2) choose your team* (3) plan the project steps (4) conduct the analysis (5) create a final report … committee (optional) Implementation Costs And External Funding Support John Bender and Steve Kulju report

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45553/psn-pdf
     October 13, 2018 - Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors … Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors … https://psnet.ahrq.gov/issue/computerized-prescriber-order-entry-related-patient-safety-reports-analysis … This follow-up study analyzed more than 1300 CPOE error reports to further classify the types of errors … https://psnet.ahrq.gov/issue/computerized-prescriber-order-entry-related-patient-safety-reports-analysis

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72555/psn-pdf
     December 09, 2020 - Development and validation of a deep learning model for detection of allergic reactions using safety event reports … Development and validation of a deep learning model for detection of allergic reactions using safety event reports … deep learning model can accurately and efficiently identify allergic reactions in hospital safety reports

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852746/psn-pdf
     August 23, 2023 - Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event reports … Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event reports … This study analyzed more than 100 serious adverse event (SAE) reports in acute care using four investigation

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47494/psn-pdf
     January 01, 2020 - This analysis of voluntary safety reports at a health system encompassing 10 hospitals found that a … higher than expected proportion of white patients were identified in safety reports overall, and that … the types of reports differed significantly for white, black, and patients of other races.

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38414/psn-pdf
     March 31, 2009 - Patient safety incidents associated with airway devices in critical care: a review of reports to the … Patient safety incidents associated with airway devices in critical care: a review of reports to the … https://psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports … The report makes recommendations for the proper use of monitoring equipment to ensure safety for intubated … https://psnet.ahrq.gov/issue/patient-safety-incidents-associated-airway-devices-critical-care-review-reports-uk-national

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42932/psn-pdf
     December 30, 2014 - SBAR improves communication and safety climate and decreases incident reports due to communication errors … SBAR improves communication and safety climate and decreases incident reports due to communication errors … https://psnet.ahrq.gov/issue/sbar-improves-communication-and-safety-climate-and-decreases-incident- reports-due … https://psnet.ahrq.gov/issue/sbar-improves-communication-and-safety-climate-and-decreases-incident-reports-due … https://psnet.ahrq.gov/issue/sbar-improves-communication-and-safety-climate-and-decreases-incident-reports-due

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836812/psn-pdf
     March 30, 2022 - They are a general term for patient safety event reporting systems where voluntary reports are made … , encourage submission of reports from a broad range of healthcare professionals, integrate mechanisms … to ensure timely review of reports, and close the loop by developing and communicating action plans … to individuals who submit reports and other stakeholders. … By celebrating employees who report patient safety hazards and shifting the focus from the number of

371. Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. | PSNet
     psnet.ahrq.gov/issue/comparing-rates-adverse-events-detected-incident-reporting-and-global-trigger-tool-systematic
     December 13, 2023 - A content analysis of accreditation reports. … Diagnostic error in the emergency department: learning from national patient safety incident report … care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports … April 1, 2020 Characterising the nature of primary care patient safety incident reports … February 1, 2017 Harms from discharge to primary care: mixed methods analysis of incident reports

372. 2014 Guide to State Adverse Event Reporting Systems. | PSNet
     psnet.ahrq.gov/issue/2014-guide-state-adverse-event-reporting-systems
     November 29, 2009 - Book/Report 2014 Guide to State Adverse Event Reporting Systems. … The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary … Report. … January 9, 2025 Patient Safety Authority Annual Reports. … December 5, 2018 Confidential Physician Feedback Reports: Designing for Optimal Impact

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47199/psn-pdf
     October 03, 2018 - 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 … https://psnet.ahrq.gov/issue/patient-safety-palliative-care-mixed-methods-study-reports-national-database … https://psnet.ahrq.gov/issue/patient-safety-palliative-care-mixed-methods-study-reports-national-database-serious … https://psnet.ahrq.gov/issue/patient-safety-palliative-care-mixed-methods-study-reports-national-database-serious

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35399/psn-pdf
     February 24, 2011 - Patient reports of undesirable events during hospitalization. … Patient reports of undesirable events during hospitalization. … https://psnet.ahrq.gov/issue/patient-reports-undesirable-events-during-hospitalization The authors surveyed … https://psnet.ahrq.gov/issue/patient-reports-undesirable-events-during-hospitalization

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35121/psn-pdf
     September 07, 2005 - Classifying laboratory incident reports to identify problems that jeopardize patient safety. … https://psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient … https://psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety … https://psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety

376. Using root cause analysis to reduce falls with injury in the psychiatric unit. | PSNet
     psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-psychiatric-unit
     September 18, 2019 - Review of alternatives to root cause analysis: developing a robust system for incident report … September 18, 2019 A review of adverse event reports from emergency departments in the … Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports … View More Related Resources Adverse Health Events in Minnesota: Annual Reports … Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports

377. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
     psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
     September 01, 2011 - evaluations or litigation, uncertainty about what to report, and doubts about whether hospitals use … In one study based at two hospitals, a third of report narratives provided insufficient information to … Contributing factors identified by hospital incident report narratives. … But if there's a very simple way of initiating an incident report from within the sign out system, then … May 21, 2014 "To Err Is Human" Report Retrospective and the Decade Ahead.

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837298/psn-pdf
     June 01, 2022 - This study used reports submitted to the internal patient safety reporting system to explore potential … implicit bias in the types and severity of reports filed against physicians. … Findings suggest a lower threshold for submitting reports against women and minoritized physicians which

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40723/psn-pdf
     August 24, 2011 - ALERT: reports of severe harm after intravenous administration of breast milk to infants. …   https://psnet.ahrq.gov/issue/alert-reports-severe-harm-after-intravenous-administration-breast-milk-infants … This announcement reports on mistaken intravenous administration of breast milk and provides recommendations … https://psnet.ahrq.gov/issue/alert-reports-severe-harm-after-intravenous-administration-breast-milk-infants

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61024/psn-pdf
     October 14, 2020 - long-term care for people with intellectual disability: an interrupted time series analysis of incident reports … term care for people with intellectual disability: an interrupted time series analysis of incident reports … to COVID- 19 coincided with an increase in aggression incidents and a decrease in medication error reports