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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74710/psn-pdf
    January 26, 2022 - evolution-anesthesia-patient-safety-movement-america-lessons-learned-and- considerations The legacy of anesthesiology as a leader in patient safety is reviewed
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73984/psn-pdf
    October 20, 2021 - Using the Diagnostic Error Evaluation and Research (DEER) taxonomy, researchers reviewed 16 records
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837426/psn-pdf
    June 15, 2022 - training in the United Kingdom identified a high rate of prescribing errors (8.9% of prescriptions reviewed
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849136/psn-pdf
    May 17, 2023 - This peer-reviewed article discusses how one organization implemented an M&M program.
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839818/psn-pdf
    November 09, 2022 - systems, error types associated with immobilization systems, and the influence of treatment position are reviewed
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35841/psn-pdf
    March 28, 2011 - https://psnet.ahrq.gov/issue/measuring-safety-climate-health-care The authors reviewed 12 studies that
  7. psnet.ahrq.gov/issue/examining-nurses-decision-process-medication-management-home-care
    December 21, 2018 - In this AHRQ-funded study, the investigators reviewed the medication management process for home care
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36368/psn-pdf
    July 08, 2008 - https://psnet.ahrq.gov/issue/systematic-review-medication-errors-pediatric-patients The authors reviewed
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867590/psn-pdf
    January 22, 2025 - Each of the four case-finding strategies was used, 703 cases were reviewed, and 32% of cases had at
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866249/psn-pdf
    July 10, 2024 - In this study, twelve months of health information technology (HIT) incidents were retrospectively reviewed
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865484/psn-pdf
    April 03, 2024 - In this study, records of patients with incidental imaging findings (IIF) were reviewed to determine
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866744/psn-pdf
    September 18, 2024 - care-concerns-and-deficiencies-facility-leaders-and-staffs-responses-following- medical This investigation from the VA Office of Inspector General (OIG) reviewed
  13. psnet.ahrq.gov/issue/system-factors-analysis-line-tube-and-drain-incidents-intensive-care-unit
    December 15, 2011 - The authors reviewed anonymous adverse event reports from an intensive care unit and analyzed the systemic
  14. psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
    January 01, 2009 - substantially in the PACS/digital environment.( 8 ) Before the advent of PACS, a radiologist typically reviewed … separation of the report (EHR) from the images (PACS) has increased the frequency with which reports are reviewed … by clinicians without the images (as in this case) and images are reviewed without the report. … In this case, the gynecologist should have reviewed the images personally before entering the OR for … quickly and efficiently launch the EHR and find pertinent information based on the imaging study being reviewed
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35727/psn-pdf
    February 22, 2006 - psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution The authors reviewed
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35592/psn-pdf
    June 17, 2010 - noise-levels-johns-hopkins-hospital The investigators conducted a noise survey at Johns Hopkins Hospital and reviewed
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35457/psn-pdf
    January 05, 2017 - examining-nurses-decision-process-medication-management-home-care In this AHRQ-funded study, the investigators reviewed
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844547/psn-pdf
    February 15, 2023 - In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836852/psn-pdf
    April 06, 2022 - and mortality to patients and play a role in malpractice claims. 498 closed malpractice claims were reviewed
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836987/psn-pdf
    April 27, 2022 - To evaluate its RR system, one hospital’s pediatric department reviewed all REACT (Rapid Escalation

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