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121. Never Events Analysis of HSIB's National Investigations Report. | PSNet
     psnet.ahrq.gov/issue/never-events-analysis-hsibs-national-investigations-report
     June 09, 2021 - Book/Report Never Events Analysis of HSIB's National Investigations Report. … Citation Text: Never Events Analysis of HSIB's National Investigations Report. … This National Learning Report provides a  thematic examination  of never events in the National Health … Citation Citation Text: Never Events Analysis of HSIB's National Investigations Report … Cause Analysis February 26, 2025 Adverse Health Events in Minnesota: Annual Reports

122. Use of prescribing safety quality improvement reports in UK general practices: a qualitative assessment. | PSNet
     psnet.ahrq.gov/issue/use-prescribing-safety-quality-improvement-reports-uk-general-practices-qualitative
     December 08, 2021 - Four themes were identified: receiving the report, facilitators and barriers to acting upon the report … , acting upon the report, and how the report contributes to a quality culture. … upon the reports. … to acting upon the reports. … opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report

123. Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project. | PSNet
     psnet.ahrq.gov/issue/hand-hygiene-project-best-practices-hospitals-participating-joint-commission-center
     May 06, 2015 - Book/Report Hand Hygiene Project: Best Practices from Hospitals Participating in … This report describes how teams participating in The Joint Commission’s Center for Transforming Healthcare … 6, 2015 Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report … More Related Resources National and State Healthcare-Associated Infections Progress … Report.

124. State Patient Safety Centers: A New Approach to Promote Patient Safety. | PSNet
     psnet.ahrq.gov/issue/state-patient-safety-centers-new-approach-promote-patient-safety
     November 29, 2009 - Book/Report State Patient Safety Centers: A New Approach to Promote Patient Safety … This report examines the various models applied in these states to design, administer, and monitor the … The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary … Report. … Safety Initiatives July 10, 2024 Adverse Health Events in Minnesota: Annual Reports

125. Commission of Inquiry on Hormone Receptor Testing. | PSNet
     psnet.ahrq.gov/issue/commission-inquiry-hormone-receptor-testing
     May 26, 2021 - Book/Report Commission of Inquiry on Hormone Receptor Testing. … The report makes numerous recommendations with respect to ethics, standards of care, and disclosure of … (Click on the volume titles on the cover page to view the full report.) … September 6, 2017 The Rebecca O'Malley Report. … June 18, 2013 Keeping the Commitment: A Progress Report on Four Early Leaders in Patient

126. Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee. | PSNet
     psnet.ahrq.gov/issue/deficiencies-care-care-coordination-and-facility-response-patient-who-died-suicide-memphis-va
     December 16, 2020 - Book/Report Deficiencies in Care, Care Coordination, and Facility Response to a Patient … Report No 19-09493-249. … Report No 19-09493-249. … Report No 19-09493-249. … January 29, 2020 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care

127. Industrial and Systems Engineering and Health Care: Critical Areas of Research: Final Report. | PSNet
     psnet.ahrq.gov/issue/industrial-and-systems-engineering-and-health-care-critical-areas-research-final-report
     November 17, 2010 - Book/Report Industrial and Systems Engineering and Health Care: Critical Areas of … Research: Final Report. … Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report. … Final Report.

128. Maryland Hospital Patient Safety Program Annual Report. | PSNet
     psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
     December 24, 2008 - Book/Report Maryland Hospital Patient Safety Program Annual Report. … Citation Text: Maryland Hospital Patient Safety Program Annual Report. … Latest report (PDF) Previous reports Save Save to your library Print Download … Final Report. … May 13, 2021 HANYS' Report on Report Cards.

129. Guide to Patient and Family Engagement: Environmental Scan Report. | PSNet
     psnet.ahrq.gov/issue/guide-patient-and-family-engagement-environmental-scan-report
     August 01, 2012 - Book/Report Guide to Patient and Family Engagement: Environmental Scan Report. … Citation Text: Guide to Patient and Family Engagement: Environmental Scan Report. … This report describes the state of currently available resources to promote patient and family engagement … August 28, 2013 2012 User Comparative Database Report: Medical Office Survey on Patient … View More Related Resources National Healthcare Quality and Disparities Reports

130. In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
     March 30, 2020 - The prior reports were more hospital-focused, and we know that most care is not delivered there these … that haven’t been addressed in past reports? … Finally, this iteration provides PSP comparison tables across all three of the reports. … Health IMPAQ International Columbia, MD References [1] AHRQ’s Making Healthcare Safer Reports … [5] Making Healthcare Safer III: Comparison Tables for Making Health Safer Reports.

131. Mid Staffordshire NHS Foundation Trust Quality Report. | PSNet
     psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report
     October 24, 2024 - Book/Report Mid Staffordshire NHS Foundation Trust Quality Report. … Citation Text: Mid Staffordshire NHS Foundation Trust Quality Report. … This report highlights insights from staff about the trust's current ability to deliver safe care and … December 3, 2014 Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for … October 23, 2023 Lessons from the Covid War: An Investigative Report.

132. Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona. | PSNet
     psnet.ahrq.gov/issue/deficiencies-quality-management-processes-and-delays-communication-test-results-and-follow
     March 01, 2023 - Book/Report Deficiencies in Quality Management Processes and Delays in the Communication … Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07. … Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07. … January 24, 2024 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care … July 13, 2022 Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental

133. Serious Reportable Events in Massachusetts. | PSNet
     psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
     May 03, 2023 - Book/Report Serious Reportable Events in Massachusetts. … Older reports are also available. … January 9, 2025 Patient Safety Authority Annual Reports. … April 30, 2024 National Healthcare Quality and Disparities Reports. … May 13, 2021 HANYS' Report on Report Cards.

134. Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities for Improvement. | PSNet
     psnet.ahrq.gov/issue/utah-tenth-anniversary-2001-2011-patient-safety-report-identifying-opportunities-improvement
     March 17, 2011 - Book/Report Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying … Citation Text: Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities … October 6, 2021 Association of patient and family reports of hospital safety climate … 2022 View More Related Resources Patient Safety Authority Annual Reports … April 30, 2024 National Healthcare Quality and Disparities Reports.

135. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. | PSNet
     psnet.ahrq.gov/issue/future-nursing-2020-2030-charting-path-achieve-health-equity
     September 12, 2018 - Book/Report The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity … This report builds on the foundation of nursing as a core care contributor. … View More Related Resources National Healthcare Quality and Disparities Reports … January 9, 2024 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care

136. Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections. | PSNet
     psnet.ahrq.gov/issue/health-care-associated-infections-hospitals-overview-state-reporting-programs-and-individual
     June 07, 2008 - Book/Report Health-Care-Associated Infections in Hospitals: An Overview of State … This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives … View More Related Resources National Healthcare Quality and Disparities Reports … January 9, 2024 National and State Healthcare-Associated Infections Progress Report.

137. Independent Neurology Inquiry. | PSNet
     psnet.ahrq.gov/issue/independent-neurology-inquiry
     November 16, 2022 - Book/Report Independent Neurology Inquiry. … The Report of the Gosport Independent Panel. … November 7, 2018 Final Report of the Ockenden Review. … The Report of the Independent Medicines and Medical Devices Safety Review. … View More Related Resources Adverse Health Events in Minnesota: Annual Reports

138. ISMP medication error report analysis. | PSNet
     psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-17
     January 17, 2018 - Commentary ISMP medication error report analysis. … Citation Text: ISMP medication error report analysis. Cohen MR; Smetzer JL. … This monthly selection of medication error reports discusses problems related to intravenous tubing misconnections … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

139. ISMP medication error report analysis. | PSNet
     psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-21
     January 17, 2018 - Commentary ISMP medication error report analysis. … Citation Text: ISMP medication error report analysis. Cohen MR; Smetzer JL. … This monthly selection of medication error reports provides examples of intravenous amphotericin mix-ups … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

140. ISMP medication error report analysis. | PSNet
     psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-36
     December 30, 2014 - Commentary ISMP medication error report analysis. … This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.