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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837768/psn-pdf
    August 03, 2022 - Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events … Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events … https://psnet.ahrq.gov/issue/comparison-voluntary-safety-reporting-system-global-trigger-tool-identifying … Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system … https://psnet.ahrq.gov/issue/comparison-voluntary-safety-reporting-system-global-trigger-tool-identifying-adverse-events
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847728/psn-pdf
    April 19, 2023 - Development and interrater agreement of a novel classification system combining medical and surgical … Development and interrater agreement of a novel classification system combining medical and surgical … https://psnet.ahrq.gov/issue/development-and-interrater-agreement-novel-classification-system-combining … This article describes the development and testing of a novel Quality Improvement Classification System … https://psnet.ahrq.gov/issue/development-and-interrater-agreement-novel-classification-system-combining-medical-and
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60910/psn-pdf
    January 01, 2021 - Hospital- and system-wide interventions for health care- associated infections: a systematic review. … Hospital- and system-wide interventions for health care-associated infections: a systematic review. … https://psnet.ahrq.gov/issue/hospital-and-system-wide-interventions-health-care-associated-infections … - systematic-review This systematic review examined effectiveness of hospital- or system-wide interventions … https://psnet.ahrq.gov/issue/hospital-and-system-wide-interventions-health-care-associated-infections-systematic-review
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837429/psn-pdf
    January 01, 2022 - Improving allergy documentation: a retrospective electronic health record system-wide patient safety … Improving allergy documentation: a retrospective electronic health record system-wide patient safety … https://psnet.ahrq.gov/issue/improving-allergy-documentation-retrospective-electronic-health-record- system-wide-patient … One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries … https://psnet.ahrq.gov/issue/improving-allergy-documentation-retrospective-electronic-health-record-system-wide-patient
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73442/psn-pdf
    June 30, 2021 - Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic. … Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic. … https://psnet.ahrq.gov/issue/burnout-and-secondary-traumatic-stress-health-system-pharmacists-during- … ; however, this is the first to focus on burnout and secondary traumatic stress (STS) among health system … https://psnet.ahrq.gov/issue/burnout-and-secondary-traumatic-stress-health-system-pharmacists-during-covid
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74268/psn-pdf
    January 19, 2022 - Potentially inappropriate prescribing and its associations with health-related and system-related outcomes … related and system?related outcomes in hospitalised older adults: A systematic review and meta? … psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-and-its-associations-health-related-and- system-related … studies found that potentially inappropriate prescribing was significantly associated with several system-related … /psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-and-its-associations-health-related-and-system-related
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60294/psn-pdf
    May 06, 2020 - Medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage … Medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage … https://psnet.ahrq.gov/issue/medically-necessary-time-sensitive-procedures-scoring-system-ethically-and … This article describes a scoring system incorporating resource limitations and COVID-19 transmission … https://psnet.ahrq.gov/issue/medically-necessary-time-sensitive-procedures-scoring-system-ethically-and-efficiently-manage
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846155/psn-pdf
    March 15, 2023 - Reduction in omission events after implementing a rapid response system: a mortality review in a department … Reduction in omission events after implementing a Rapid Response System: a mortality review in a department … https://psnet.ahrq.gov/issue/reduction-omission-events-after-implementing-rapid-response-system- mortality-review … https://psnet.ahrq.gov/issue/reduction-omission-events-after-implementing-rapid-response-system-mortality-review … https://psnet.ahrq.gov/issue/reduction-omission-events-after-implementing-rapid-response-system-mortality-review
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74867/psn-pdf
    February 23, 2022 - Health care safety during the pandemic and beyond-- building a system that ensures resilience. … Health care safety during the pandemic and beyond--building a system that ensures resilience. … https://psnet.ahrq.gov/issue/health-care-safety-during-pandemic-and-beyond-building-system-ensures- … They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable … https://psnet.ahrq.gov/issue/health-care-safety-during-pandemic-and-beyond-building-system-ensures-resilience
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848124/psn-pdf
    April 26, 2023 - We designed a system specifically for that setting. … of the monitoring system, were on site for weeks. … For all of these system changes, we always did a workshop where we would walk through how the new system … was implemented, and continue to improve the system as needed. … If you perturb the system, you’re going to get a different output.
  11. psnet.ahrq.gov/issue/early-prognostic-value-medical-emergency-team-calling-criteria-patients-admitted-intensive
    March 24, 2021 - November 11, 2020 Mature rapid response system and potentially avoidable cardiopulmonary … March 24, 2011 We are not there yet: a qualitative system probing study of a hospital … rapid response system. … probing study of a hospital rapid response system. … June 3, 2010 Uncovering system errors using a rapid response team: cross-coverage caught
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851187/psn-pdf
    July 05, 2023 - Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID … creation of healthcare safety and healthcare system resilience: the case of COVID?19. … https://psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system- … activities they undertook to keep themselves and others safe, and their understanding of healthcare system … https://psnet.ahrq.gov/issue/patient-and-public-co-creation-healthcare-safety-and-healthcare-system-resilience-case-covid
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60156/psn-pdf
    March 25, 2020 - The cognitive health system. March 25, 2020 Coiera E. The cognitive health system. … https://psnet.ahrq.gov/issue/cognitive-health-system This article discusses the influence of artificial … as symptom checkers) as well as approaches to exploit cyber-social systems within a learning health system … https://psnet.ahrq.gov/issue/cognitive-health-system https://psnet.ahrq.gov/issue/can-social-media-be-used-hospital-quality-improvement-tool
  14. psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
    March 01, 2019 - the local care–providing entities of the system. … Meeting and various communication pathways, including a system safety blog. … across the entire system. … It was a complex system with offices all over Metro Boston. … If a system were to become one big system with an interoperable EHR, that's fabulous.
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60669/psn-pdf
    July 08, 2020 - Participation in a system-thinking simulation experience changes adverse event reporting. … Participation in a system-thinking simulation experience changes adverse event reporting. … https://psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event … https://psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event-reporting … https://psnet.ahrq.gov/issue/participation-system-thinking-simulation-experience-changes-adverse-event-reporting
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74014/psn-pdf
    October 27, 2021 - Adopting system models for multiple incident analysis: utility and usability. … https://psnet.ahrq.gov/issue/adopting-system-models-multiple-incident-analysis-utility-and-usability … This qualitative study conducted in the United Kingdom evaluated the utility of two system models – … https://psnet.ahrq.gov/issue/adopting-system-models-multiple-incident-analysis-utility-and-usability … https://psnet.ahrq.gov/issue/err-system-comparison-methodologies-investigation-adverse-outcomes-healthcare
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73569/psn-pdf
    August 04, 2021 - Enabling a learning healthcare system with automated computer protocols that produce replicable and … Enabling a learning healthcare system with automated computer protocols that produce replicable and … https://psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce … https://psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce-replicable-and … https://psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce-replicable-and
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73249/psn-pdf
    May 12, 2021 - I-PASS handover system: a decade of evidence demands action. May 12, 2021 Shahian DM. … I-PASS handover system: a decade of evidence demands action. … https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action The I-PASS structured … https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action https://psnet.ahrq.gov … changes-medical-errors-after-implementation-handoff-program https://psnet.ahrq.gov/issue/large-scale-implementation-i-pass-handover-system-academic-medical-centre
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47265/psn-pdf
    February 22, 2019 - Introduction of a mobile adverse event reporting system is associated with participation in adverse … Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event … https://psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838142/psn-pdf
    September 21, 2022 - A health system that won't learn from its mistakes. September 21, 2022 Keller C. … A health system that won't learn from its mistakes. Health Aff (Millwood). 2022;41(9):1353-1356. … https://psnet.ahrq.gov/issue/health-system-wont-learn-its-mistakes Communication failures due to hierarchy … for improvement such as assignment of accountability for error and commitment to the learning health system … https://psnet.ahrq.gov/issue/health-system-wont-learn-its-mistakes https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors

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