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psnet.ahrq.gov/node/48173/psn-pdf
August 28, 2019 - Analysis
of 5 years' experience from the Leeds radiology
educational cases meetings identifies common … Analysis of 5 years' experience from the
Leeds radiology educational cases meetings identifies common … https://psnet.ahrq.gov/issue/does-learning-mistakes-have-be-painful-analysis-5-years-experience-leeds … their analysis of more than 600 cases discussed at educational radiology conferences over several years … https://psnet.ahrq.gov/issue/does-learning-mistakes-have-be-painful-analysis-5-years-experience-leeds-radiology
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psnet.ahrq.gov/issue/building-safer-systems-through-critical-occurrence-reviews-nine-years-learning
July 05, 2017 - Study
Building safer systems through critical occurrence reviews: nine years of learning … Building safer systems through critical occurrence reviews: nine years of learning. … Building safer systems through critical occurrence reviews: nine years of learning.
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psnet.ahrq.gov/issue/20-years-after-err-human-leapfrog-hospital-safety-grades-prove-transparency-can-save-lives
December 11, 2019 - Press Release/Announcement
20 Years After “To Err is Human”, Leapfrog Hospital Safety … Citation Text:
20 Years After “To Err is Human”, Leapfrog Hospital Safety Grades Prove Transparency … Linkedin
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20 Years
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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - Over the past two years, the patient had been placed on oral contraceptives, but these had not stanched … This young woman experienced abnormal bleeding for 2 years until she was properly diagnosed. … fail to receive timely, or sometimes any, diagnostic resolution.( 13 )
Even as we focus on the 2 years … Cervical neoplasia is a slow growing disease, taking 10-30 years to progress from Human Papilloma Virus … Once cancer invades, it takes several years to progress from a localized to a regional and then distantly
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psnet.ahrq.gov/issue/errors-stat-laboratory-changes-type-and-frequency-1996
December 21, 2016 - Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem. 2007;53(7):1338-42. … The investigators conducted a study to compare clinical laboratory error data to that collected 10 years … Errors in a stat laboratory: types and frequencies 10 years later.
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psnet.ahrq.gov/issue/adverse-event-reporting-lessons-learned-4-years-florida-office-data
November 16, 2022 - Study
Adverse event reporting: lessons learned from 4 years of Florida office data … Adverse event reporting: lessons learned from 4 years of Florida office data. … Adverse event reporting: lessons learned from 4 years of Florida office data.
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psnet.ahrq.gov/issue/doctors-turned-my-sister-away-less-two-years-later-she-died-cervical-cancer
September 09, 2020 - Newspaper/Magazine Article
Doctors turned my sister away; less than two years later … Citation Text:
Doctors turned my sister away; less than two years later she died of cervical cancer … Cite
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Doctors turned my sister away; less than two years
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - Over the eleven years the program was employed at the University of Kansas Hospital, there was a progressive … Anecdotal reports over the first 3 years of implementation suggest that clinician performance during … reduction in cesarean delivery direct costs for cesarean delivery, an estimated $4.4 million over 7 years … Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series … Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series
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psnet.ahrq.gov/issue/how-columbia-ignored-women-undermined-prosecutors-and-protected-predator-more-20-years
May 31, 2023 - How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years … Text:
How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years … Text:
How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years
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psnet.ahrq.gov/node/34848/psn-pdf
February 17, 2011 - Improving patient safety—five years after the IOM report. … Improving Patient Safety — Five Years after the IOM Report. … https://psnet.ahrq.gov/issue/improving-patient-safety-five-years-after-iom-report
This commentary offers … https://psnet.ahrq.gov/issue/improving-patient-safety-five-years-after-iom-report
https://psnet.ahrq.gov … https://psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
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psnet.ahrq.gov/issue/adverse-events-robotic-surgery-retrospective-study-14-years-fda-data
June 24, 2020 - Study
Adverse events in robotic surgery: a retrospective study of 14 years of FDA … Adverse Events in Robotic Surgery: A Retrospective Study of 14 Years of FDA Data. … Adverse Events in Robotic Surgery: A Retrospective Study of 14 Years of FDA Data.
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psnet.ahrq.gov/issue/what-have-we-learnt-after-15-years-research-weekend-effect
December 02, 2020 - Commentary
What have we learnt after 15 years of research into the 'weekend effect … What have we learnt after 15 years of research into the 'weekend effect'? … What have we learnt after 15 years of research into the 'weekend effect'?
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psnet.ahrq.gov/issue/mid-staffs-scandal-10-years-inquiry-chair-worries-nhs-staff-too-scared-speak
December 18, 2019 - Newspaper/Magazine Article
Mid Staffs scandal: 10 years on, inquiry chair worries … Citation Text:
Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak … Cite
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Mid Staffs scandal: 10 years
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psnet.ahrq.gov/issue/communication-gaps-and-readmissions-hospital-patients-aged-75-years-and-older-observational
July 19, 2023 - Study
Communication gaps and readmissions to hospital for patients aged 75 years … Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study … Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study
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psnet.ahrq.gov/issue/how-can-specialist-investigation-agencies-inform-system-wide-learning-patient-safety
January 29, 2014 - A qualitative study of perspectives on the early years of the English Healthcare Safety Investigation … A qualitative study of perspectives on the early years of the English healthcare safety investigation … A qualitative study of perspectives on the early years of the English healthcare safety investigation … May 3, 2023
20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report
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psnet.ahrq.gov/node/37308/psn-pdf
January 05, 2012 - Effect of a rapid response system for patients in shock on
time to treatment and mortality during 5 years … Effect of a rapid response system for patients in shock on time to
treatment and mortality during 5 years … psnet.ahrq.gov/issue/effect-rapid-response-system-patients-shock-time-treatment-and-mortality-
during-5-years … Investigators compared
outcomes 2.5 years before and 5 years after implementation of their RRS in demonstrating … psnet.ahrq.gov/issue/effect-rapid-response-system-patients-shock-time-treatment-and-mortality-during-5-years
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psnet.ahrq.gov/node/860722/psn-pdf
January 17, 2024 - Ten years of incident reports on in-hospital cardiac arrest
- Are they useful for improvements? … Ten years of incident reports on in-hospital cardiac arrest – Are they useful for improvements? … https://psnet.ahrq.gov/issue/ten-years-incident-reports-hospital-cardiac-arrest-are-they-useful-
improvements … https://psnet.ahrq.gov/issue/ten-years-incident-reports-hospital-cardiac-arrest-are-they-useful-improvements … https://psnet.ahrq.gov/issue/ten-years-incident-reports-hospital-cardiac-arrest-are-they-useful-improvements
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psnet.ahrq.gov/issue/mortality-among-patients-va-hospitals-first-2-years-following-acgme-resident-duty-hour-reform
February 18, 2011 - Classic
Mortality among patients in VA hospitals in the first 2 years … Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform … Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform … February 17, 2011
Mortality among hospitalized Medicare beneficiaries in the first 2 years
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psnet.ahrq.gov/issue/importance-prevention-and-early-intervention-adverse-events-pediatric-cardiac-catheterization
March 24, 2019 - prevention and early intervention of adverse events in pediatric cardiac catheterization: a review of three years … prevention and early intervention of adverse events in pediatric cardiac catheterization: a review of three years … prevention and early intervention of adverse events in pediatric cardiac catheterization: a review of three years
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psnet.ahrq.gov/issue/surgical-teams-attitudes-about-surgical-safety-and-surgical-safety-checklist-10-years
March 17, 2021 - Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years … Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational … Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational