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421. In Conversation With…Kaveh G. Shojania, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
     September 01, 2011 - He led the team that produced the 2001 AHRQ evidence report, Making Health Care Safer , and was awarded … But if there's a very simple way of initiating an incident report from within the sign out system, then … 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.

422. Your safer-surgery survival guide. | PSNet
     psnet.ahrq.gov/issue/your-safer-surgery-survival-guide
     November 15, 2024 - Consumer reports. 2013;78(9):31-41. … Facebook Twitter Linkedin Copy URL November 5, 2014 Consumer reports … This report analyzed Medicare claims data on 27 types of procedures to develop surgical safety ratings … Consumer reports. 2013;78(9):31-41.

423. Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care. | PSNet
     psnet.ahrq.gov/issue/analysis-reported-suicide-safety-events-among-veterans-who-received-treatment-through
     August 21, 2019 - bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports … Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports … Analysis of incident reports from a patient safety organization. … Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44966/psn-pdf
     March 16, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance. … https://psnet.ahrq.gov/issue/confidential-physician-feedback-reports-designing-optimal-impact-performance … https://psnet.ahrq.gov/issue/confidential-physician-feedback-reports-designing-optimal-impact-performance

425. Analysis of risk factors for patient safety events occurring in the emergency department. | PSNet
     psnet.ahrq.gov/issue/analysis-risk-factors-patient-safety-events-occurring-emergency-department
     January 26, 2022 - bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports … Analysis of incident reports from a patient safety organization. … errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports … September 30, 2020 A review of adverse event reports from emergency departments in the

426. Development of a preliminary patient safety classification system for generative AI. | PSNet
     psnet.ahrq.gov/issue/development-preliminary-patient-safety-classification-system-generative-ai
     December 21, 2022 - 2024 Artificial intelligence related safety issues associated with FDA medical device reports … safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports … A natural language processing approach to categorise contributing factors from patient safety event reports … 2023 A machine learning approach to reclassifying miscellaneous patient safety event reports

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40324/psn-pdf
     April 14, 2011 - patient records reported by patients and healthcare professionals via complaints, claims and incident reports … patient records reported by patients and healthcare professionals via complaints, claims and incident reports … what-extent-are-adverse-events-found-patient-records-reported-patients-and- healthcare This Dutch study found that patient complaints, malpractice claims, and incident reports

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45416/psn-pdf
     August 24, 2016 - /issue/framework-assess-patient-reported-adverse-outcomes-arising-during- hospitalization Patient reports … This study used patient reports of adverse outcomes to develop a framework for identifying adverse events … The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for

429. Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. | PSNet
     psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events
     October 07, 2020 - patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports … 2022 Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports … March 18, 2020 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46478/psn-pdf
     March 27, 2018 - Promote a culture of safety with good catch reports. … https://psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports Near misses or good catches present … https://psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports https://psnet.ahrq.gov/issue/near-misses-are-opportunity-improve-patient-safety-adapting-strategies-high-reliability

431. Medication safety in the emergency department: a study of serious medication errors reported by 101 hospitals from 2011 to 2020. | PSNet
     psnet.ahrq.gov/issue/medication-safety-emergency-department-study-serious-medication-errors-reported-101-hospitals
     March 24, 2021 - Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports … 2022 Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports … Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports … patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports

432. When work harms: how better understanding of avoidable employee harm can improve employee safety, patient safety and healthcare quality. | PSNet
     psnet.ahrq.gov/issue/when-work-harms-how-better-understanding-avoidable-employee-harm-can-improve-employee-safety
     December 16, 2015 - Same Author(s) Harms from discharge to primary care: mixed methods analysis of incident reports … Diagnostic error in the emergency department: learning from national patient safety incident report … January 15, 2020 Characterising the nature of primary care patient safety incident reports … September 26, 2018 Nature of blame in patient safety incident reports: mixed methods … or alongside emergency departments: incorporating realist methodology into patient safety incident report

433. Strategies and Approaches for Investigating Patient Safety Events | PSNet
     psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
     March 15, 2025 - They are a general term for patient safety event reporting systems where voluntary reports are made by … to individuals who submit reports and other stakeholders. … By celebrating employees who report patient safety hazards and shifting the focus from the number of … Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S … authors has any affiliation or financial involvement that conflicts with the material presented in this report

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45292/psn-pdf
     September 07, 2016 - psnet.ahrq.gov/issue/electronic-approaches-making-sense-text-adverse-event-reporting-system Voluntary incident reports … This study found that a machine learning approach to electronically analyze incident reports successfully … The authors conclude that it is feasible to apply automated text analysis to incident reports to categorize

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42737/psn-pdf
     November 20, 2019 - HANYS' Report on Report Cards. … https://psnet.ahrq.gov/issue/hanys-report-report-cards This publication assessed 12 widely disseminated … hospital report cards by criteria including transparency of methodology, evidence-based measures, and … While inconsistent methods across reports hindered direct comparisons, a few reports received high marks … https://psnet.ahrq.gov/issue/hanys-report-report-cards https://psnet.ahrq.gov/issue/publicly-available-hospital-comparison-web-sites-determination-useful-valid-and-appropriate

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44120/psn-pdf
     November 06, 2015 - This study demonstrated that modeling based on automated data mining of event reports could identify … reports that were most likely to be associated with subsequent malpractice claims. … programs, could be deployed more efficiently using an automated algorithm to detect high-risk event reports

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35138/psn-pdf
     July 10, 2008 - adverse-drug-event-surveillance-and-drug-withdrawals-united-states-1969- 2002 This study analyzed reports … Using more than 30 years of collected data, investigators discovered nearly 2.3 million case reports … These reports resulted in additional safety warnings, a greater list of known ADEs with specific drugs

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867146/psn-pdf
     November 13, 2024 - ://psnet.ahrq.gov/issue/social-determinants-health-and-patient-safety-analysis-patient-safety-event-reports-related … ://psnet.ahrq.gov/issue/social-determinants-health-and-patient-safety-analysis-patient-safety-event-reports-related

439. Safety incidents in the primary care office setting. | PSNet
     psnet.ahrq.gov/issue/safety-incidents-primary-care-office-setting
     October 12, 2016 - Given the known under-reporting of adverse events, this report likely underestimates the frequency of … the Same Author(s) 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 … September 26, 2018 Nature of blame in patient safety incident reports: mixed methods … Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866698/psn-pdf
     September 11, 2024 - https://psnet.ahrq.gov/issue/non-clinical-errors-using-voice-recognition-dictation-software-radiology-reports … https://psnet.ahrq.gov/issue/non-clinical-errors-using-voice-recognition-dictation-software-radiology-reports