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381. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37446/psn-pdf
     January 06, 2017 - How useful are voluntary medication error reports? … How useful are voluntary medication error reports? The case of warfarin-related medication errors. … https://psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related- … https://psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors … https://psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors

382. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41437/psn-pdf
     January 03, 2017 - Making the transition to nursing bedside shift reports. … Making the transition to nursing bedside shift reports. … https://psnet.ahrq.gov/issue/making-transition-nursing-bedside-shift-reports Efforts to improve communication … precede such an intervention and the barriers associated with nursing resistance to bedside shift reports … https://psnet.ahrq.gov/issue/making-transition-nursing-bedside-shift-reports https://psnet.ahrq.gov/primer

383. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38198/psn-pdf
     May 05, 2018 - ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events. … https://psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious- … adverse-drug-events This newsletter highlights learnings from ISMP's QuarterWatch report, a pilot program … https://psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious-adverse-drug-events … https://psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious-adverse-drug-events

384. 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

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60199/psn-pdf
     April 08, 2020 - 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

386. 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

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74033/psn-pdf
     November 03, 2021 - Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports … Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports … In this study, usability issues related to eMAR contributed to 473 patient safety event reports.

388. 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

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34069/psn-pdf
     April 12, 2011 - Patient reports of preventable problems and harms in primary health care. … Patient reports of preventable problems and harms in primary health care. … https://psnet.ahrq.gov/issue/patient-reports-preventable-problems-and-harms-primary-health-care Through … interviews with patients, this AHRQ-funded study found that patients were more likely to report breakdowns … https://psnet.ahrq.gov/issue/patient-reports-preventable-problems-and-harms-primary-health-care https

390. 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

391. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39751/psn-pdf
     August 11, 2010 - Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. … Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents. … https://psnet.ahrq.gov/issue/interpreting-adverse-drug-reaction-adr-reports-hospital-patient-safety-incidents … https://psnet.ahrq.gov/issue/interpreting-adverse-drug-reaction-adr-reports-hospital-patient-safety-incidents

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74705/psn-pdf
     January 26, 2022 - https://psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research … - patient-safety The release of the Institute of Medicine (IOM)’s To Err is Human report in 1999 was … but that the themes of recent research do not necessarily align with the initial focus of the IOM report … https://psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research-patient-safety … https://psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research-patient-safety

393. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40160/psn-pdf
     January 19, 2011 - Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental … https://psnet.ahrq.gov/issue/morphine-sulfate-oral-solution-100-mg-5-ml-20-mgml-medication-use-error- reports-accidental … https://psnet.ahrq.gov/issue/morphine-sulfate-oral-solution-100-mg-5-ml-20-mgml-medication-use-error-reports-accidental … https://psnet.ahrq.gov/issue/morphine-sulfate-oral-solution-100-mg-5-ml-20-mgml-medication-use-error-reports-accidental

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45562/psn-pdf
     October 12, 2016 - 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 … https://psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england … https://psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national … https://psnet.ahrq.gov/issue/characterising-nature-primary-care-patient-safety-incident-reports-england-and-wales-national

395. 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.

396. Advancing Health Care Safety for All. | PSNet
     psnet.ahrq.gov/issue/advancing-health-care-safety-all
     July 19, 2024 - RIS Download Citation Related Resources Annual Speak Up Data Reports … July 19, 2024 Adverse Health Events in Minnesota: Annual Reports. … May 16, 2018 Serious Adverse Events Reports.

397. Understanding the types and effects of clinical interruptions and distractions recorded in a multihospital patient safety reporting system. | PSNet
     psnet.ahrq.gov/issue/understanding-types-and-effects-clinical-interruptions-and-distractions-recorded
     February 22, 2019 - From the Same Author(s) 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 … Social determinants of health and patient safety: an analysis of patient safety event reports … May 29, 2024 A text mining approach to categorize patient safety event reports by medication

398. Learning Management System. | PSNet
     psnet.ahrq.gov/issue/learning-management-system
     April 30, 2024 - Related Resources From the Same Author(s) Patient Safety Authority Annual Reports … Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports … September 25, 2019 CHPSO Annual Reports.

399. Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary | PSNet
     psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
     February 26, 2025 - John Bender and Steve Kulju, two members of the NCPS team, report that NCPS piloted CPRA in 2020 using … and 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

400. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39090/psn-pdf
     November 11, 2009 - Nurse reports of adverse events during sedation procedures at a pediatric hospital. … Nurse reports of adverse events during sedation procedures at a pediatric hospital. … https://psnet.ahrq.gov/issue/nurse-reports-adverse-events-during-sedation-procedures-pediatric-hospital … This study discovered that perianesthesia nurses more consistently report serious adverse events compared … https://psnet.ahrq.gov/issue/nurse-reports-adverse-events-during-sedation-procedures-pediatric-hospital