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Crandall KM, Almuhanna A, Cady R, et al. Pediatr Qual Saf. 2018;3:e072.
Crandall KM ; Almuhanna A ; Cady R; et al. 10,000 good catches: increasing safety event reporting in a pediatric health care system. Pediatr Qual Saf. 2018; 3: e072
Incident reporting is widely utilized to detect adverse events and near misses, but underreporting remains a problem. This study describes a quality improvement initiative to increase event reporting across a pediatric health care system.
A surgeon so bad it was criminal.
Biel L. ProPublica. October 2, 2018.
Center for Leadership, Innovation and Research in EMS.
PO Box 2286, St. Cloud, MN, 56302.
Identifying health information technology related safety event reports from patient safety event report databases.
Fong A, Adams KT, Gaunt MJ, Howe JL, Kellogg KM, Ratwani RM. J Biomed Inform. 2018;86:135-142.
Implementing safety hotlines: Stamford Health's experience and future opportunities.
Cardiello R, Johnston S, Kiely S. J Healthc Risk Manag. 2018 Sep 5; [Epub ahead of print].
Reporting Patient Safety Events
Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.
Mannion R, Blenkinsopp J, Powell M, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
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].
The dilemma of patient safety work: perceptions of hospital middle managers.
Sanner M, Halford C, Vengberg S, Röing M. J Healthc Risk Manag. 2018 Jul 2; [Eub ahead of print].
AORN Position Statement on Criminalization of Human Errors in the Perioperative Setting.
AORN J. 2018;108:64-65.
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].
Understanding procedural violations using Safety-I and Safety-II: the case of community pharmacies.
Jones CEL, Phipps DL, Ashcroft DM. Safety Sci. 2018;105:114-120.
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.
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.
Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns.
Martin GP, Aveling EL, Campbell A, et al. BMJ Qual Saf. 2018;27:710-717.
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.
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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