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Headley M. Patient Saf Qual Healthc. April 5, 2017.
This magazine article explores the need for robust research and effective reporting to better understand the prevalence of medical errors and how to prevent them. Strategies discussed include reducing variation on measures collected and developing a culture of reporting.
Reporting Patient Safety Events
Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and complaint data.
de Vos MS, Hamming JF, Chua-Hendriks JJC, Marang-van de Mheen PJ. BMJ Qual Saf. 2018 Jul 21; [Epub ahead of print].
Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.
Tawfik DS, Profit J, Morgenthaler TI, et al. Mayo Clin Proc. 2018 Jul 9; [Epub ahead of print].
Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review.
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
Reporting adverse events in a war zone.
Arie S. BMJ. 2018;361:k2286.
Introduction of a mobile adverse event reporting system is associated with participation in adverse event reporting.
Rubin DS, Pesyna C, Jakubczyk S, Liao C, Tung A. Am J Med Qual. 2018 Jun 1; [Epub ahead of print].
Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data
Collins S, Couture B, Dykes P, et al. JAMIA Open. 2018;1:20–25.
Preventing newborn falls and drops.
Quick Safety. March 27, 2018;(40):1-2.
ISMP Follow-up Survey on Smart Pump Data Usage.
Institute for Safe Medication Practices.
Incident reporting to improve patient safety: the effects of process variance on pediatric patient safety in the emergency department.
O'Connell KJ, Shaw KN, Ruddy RM, et al; Pediatric Emergency Care Applied Research Network. Pediatr Emerg Care. 2018;34:237-242.
10,000 good catches: increasing safety event reporting in a pediatric health care system.
Crandall KM, Almuhanna A, Cady R, et al. Pediatr Qual Saf. 2018;3:e072.
The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database.
Lawal OD, Mohanty M, Elder H, et al. Expert Opin Drug Saf. 2018;17:347-357.
The hidden cost of regulation: the administrative cost of reporting serious reportable events.
Blanchfield BB, Acharya B, Mort E. Jt Comm J Qual Patient Saf. 2018;44:212–218.
Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.
Archer S, Hull L, Soukup T, et al. BMJ Open. 2017;7:e017155.
Using a modified A3 lean framework to identify ways to increase students' reporting of mistreatment behaviors.
Ross PT, Abdoler E, Flygt L, Mangrulkar RS, Santen SA. Acad Med. 2018;93:606-611.
Are we missing the near misses in the OR? Underreporting of safety incidents in pediatric surgery.
Hamilton EC, Pham DH, Minzenmayer AN, et al. J Surg Res. 2018;221:336-342.
The emotional fallout from the culture of blame and shame.
Ferguson CC. JAMA Peds. 2017;171:1141.
Public reporting of surgical outcomes: surgeons, hospitals, or both?
Jha AK. JAMA. 2017;318:1429-1430.
Same behavior, different provider: American medical students' attitudes toward reporting risky behaviors committed by doctors, nurses, and classmates.
Aggarwal S, Kheriaty A. AJOB Empir Bioeth. 2018;9:12-18.
Incident reporting behaviours following the Francis report: a cross-sectional survey.
Archer G, Colhoun A. J Eval Clin Pract. 2018;24:362-368.
Nature of blame in patient safety incident reports: mixed methods analysis of a national database.
Cooper J, Edwards A, Williams H, et al. Ann Fam Med. 2017;15:455-461.
Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation.
Wolf DA, Drake SA, Snow FK. Am J Forensic Med Pathol. 2017;38:294-297.
Intraoperative surgical performance measurement and outcomes: choose your tools carefully.
Aggarwal R. JAMA Surg. 2017;152:995-996.
Promote a culture of safety with good catch reports.
Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14.
Time for transparent standards in quality reporting by health care organizations.
Pronovost PJ, Wu AW, Austin JM. JAMA. 2017;318:701-702.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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