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  1. Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia. | PSNet

    psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
    July 26, 2023 - Report No 21-03349-186. … Report No 21-03349-186. … July 26, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental … April 19, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care … April 19, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental

  2. Characteristics of Weekday and Weekend Hospital Admissions, 2007. | PSNet

    psnet.ahrq.gov/issue/characteristics-weekday-and-weekend-hospital-admissions-2007
    September 15, 2010 - Book/Report Characteristics of Weekday and Weekend Hospital Admissions, 2007. … Using data from the Healthcare Cost and Utilization Project , this report analyzed characteristics of … View More Related Resources National Healthcare Quality and Disparities Reports … Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report.

  3. Fluorouracil Incident Root Cause Analysis Report. | PSNet

    psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
    September 02, 2014 - Book/Report Fluorouracil Incident Root Cause Analysis Report. … Citation Text: Fluorouracil Incident Root Cause Analysis Report. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … May 2, 2018 ISMP medication error report analysis.

  4. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007. | PSNet

    psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2007
    April 24, 2007 - Book/Report Improving America's Hospitals: The Joint Commission's Annual Report on … Citation Text: Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety … This report summarizes the quality and safety of care delivered to hospitalized patients between 2002 … The report suggests that hospital performance consistently improved from year to year as measured by … 2022 View More Related Resources Patient Safety Authority Annual Reports

  5. Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. | PSNet

    psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and-care-patient-chico-community-based-outpatient
    November 29, 2023 - Report no. 22-01363-52. … Report no. 22-01363-52. … January 24, 2024 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care … July 27, 2022 Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental … December 14, 2022 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care

  6. Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida. | PSNet

    psnet.ahrq.gov/issue/patient-suicide-locked-mental-health-unit-west-palm-beach-va-medical-center-florida
    January 24, 2024 - Report No. 19-07429-195. … Report No. 19-07429-195. Hospitalized patient suicide is a sentinel event . … Report No. 19-07429-195. … July 5, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination … April 5, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental

  7. The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. | PSNet

    psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient-harm
    October 12, 2022 - Report No. 22-01137-204. … Report No. 22-01137-204. … Report No. 22-01137-204. … Related Resources From the Same Author(s) Comprehensive Healthcare Inspection Summary … July 13, 2022 Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental

  8. Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. | PSNet

    psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
    November 06, 2015 - Book/Report Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. … Citation Text: Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. Francis R. … November 16, 2005 The Report of the Morecambe Bay Investigation. … View More Related Resources National Healthcare Quality and Disparities Reports … Final Report.

  9. MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine's Call to Action (2003-2006 Findings and Trends 2002-2006). | PSNet

    psnet.ahrq.gov/issue/medmarx-data-report-report-relationship-drug-names-and-medication-errors-response-institute
    March 21, 2007 - Press Release/Announcement MEDMARX Data Report: A Report on the Relationship of Drug … Citation Text: MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication Errors … This report provides an analysis of MEDMARX data from 870 hospitals on medication errors related to … Final Report. May 25, 2016 Mistaking error. … August 28, 2019 ISMP medication error report analysis.

  10. Report on the Burden of Endemic Health Care–Associated Infection Worldwide. | PSNet

    psnet.ahrq.gov/issue/report-burden-endemic-health-care-associated-infection-worldwide
    November 02, 2022 - Book/Report Report on the Burden of Endemic Health Care–Associated Infection Worldwide … 2013 View More Related Resources Patient Safety Authority Annual Reports … April 30, 2024 National Healthcare Quality and Disparities Reports. … January 9, 2024 MHA and MHA Keystone Center Annual Reports. … Final Technical Report January 2009.

  11. Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints. | PSNet

    psnet.ahrq.gov/issue/community-living-centers-va-needs-strengthen-its-approach-addressing-resident-complaints
    October 12, 2022 - Book/Report Community Living Centers: VA Needs to Strengthen Its Approach for Addressing … This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking … View More Related Resources National Healthcare Quality and Disparities Reports … February 1, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care … The Report of the Independent Medicines and Medical Devices Safety Review.

  12. Correlates of Medication Error in Hospitals. | PSNet

    psnet.ahrq.gov/issue/correlates-medication-error-hospitals
    August 24, 2022 - Book/Report Correlates of Medication Error in Hospitals. … Catalogue no. 82-003-X Health Reports.   … Evidence Report/Technology Assessment. … Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report.

  13. NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, 2021. | PSNet

    psnet.ahrq.gov/issue/ncicle-pathways-excellence-expectations-optimal-clinical-learning-environment-achieve-safe
    October 18, 2017 - Book/Report NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning … This report discusses characteristics of an environment that nurtures learning across disciplines in … Free full text Related reports Save Save to your library Print Download PDF … October 18, 2017 ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient … April 28, 2021 National Report of Findings 2016: Issue Brief No. 2: Patient Safety.

  14. ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events. | PSNet

    psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious-adverse-drug-events
    June 10, 2018 - in reports of serious adverse drug events. … Citation Text: ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse … shows sharp increase in reports of serious adverse drug events. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP QuarterWatch Reports.

  15. The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview. | PSNet

    psnet.ahrq.gov/issue/patient-safety-initiative-americas-public-hospitals-year-one-overview
    July 28, 2013 - Book/Report The Patient Safety Initiative at America’s Public Hospitals: The Year … This report describes a collaborative effort to engage public hospitals in patient safety work and highlights … View More Related Resources MHA and MHA Keystone Center Annual Reports … 2016 America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report … August 9, 2013 Keeping the Commitment: A Progress Report on Four Early Leaders in Patient

  16. The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment. | PSNet

    psnet.ahrq.gov/issue/effect-health-care-working-conditions-patient-safety-evidence-reporttechnology-assessment
    December 18, 2008 - Evidence Report/Technology Assessment. … Evidence Report/Technology Assessment. … Evidence Report/Technology Assessment. … Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report.

  17. Adverse Health Events in Minnesota: Annual Reports. | PSNet

    psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report
    February 28, 2015 - Book/Report Adverse Health Events in Minnesota: Annual Reports. … Citation Text: Adverse Health Events in Minnesota: Annual Reports. … Since 2003, Minnesota hospitals have been required to report such incidents. … Reports from previous years are available. … Latest report (PDF) Report archive Related information Related news article Save

  18. Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. | PSNet

    psnet.ahrq.gov/issue/deficiencies-emergent-and-outpatient-care-patient-alcohol-use-disorder-richard-l-roudebush-va
    July 13, 2022 - Report no. 21-03680-80. … Report no. 21-03680-80. … Report no. 21-03680-80. … July 13, 2022 Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental … January 24, 2024 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care

  19. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet

    psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
    October 12, 2022 - Report No. 22-00818-03. … Report No. 22-00818-03. … Related Resources From the Same Author(s) Comprehensive Healthcare Inspection Summary … December 21, 2022 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care … The Report of the Independent Medicines and Medical Devices Safety Review.

  20. Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being. | PSNet

    psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
    April 28, 2021 - Book/Report Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating … This report summarizes a leadership discussion examining systemic factors that detract from healthcare … April 28, 2021 ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient … October 18, 2017 National Report of Findings 2016: Issue Brief No. 2: Patient Safety. … March 1, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care
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