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161. Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia. | PSNet
     psnet.ahrq.gov/issue/deficient-care-patient-who-died-suicide-and-facility-leaders-response-charlie-norwood-va
     November 29, 2023 - Book/Report Deficient Care of a Patient Who Died by Suicide and Facility Leaders' …   Report no. 22-01116-110. … Report no. 22-01116-110. Death of a patient by suicide is a sentinel event. …   Report no. 22-01116-110. … January 24, 2024 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care

162. Report faults Children's Hospital for medication errors. | PSNet
     psnet.ahrq.gov/issue/report-faults-childrens-hospital-medication-errors
     August 24, 2016 - Newspaper/Magazine Article Report faults Children's Hospital for medication errors … Citation Text: Report faults Children's Hospital for medication errors. Kowalczyk L. … This news article reports on serious medication errors that occurred at Children's Hospital in 2017, … Linkedin Copy URL Cite Citation Citation Text: Report

163. Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS. | PSNet
     psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
     March 04, 2010 - Book/Report Mind the Implementation Gap. … This report examines large system failures in the UK National Health Service to suggest actions that … The publication highlights how public investigations, government reports , legal actions, and patient … November 16, 2022 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care … The Report of the Independent Medicines and Medical Devices Safety Review.

164. Getting doctors to report medical errors: project DISCLOSE. | PSNet
     psnet.ahrq.gov/issue/getting-doctors-report-medical-errors-project-disclose
     January 07, 2011 - Study Getting doctors to report medical errors: project DISCLOSE. … Getting doctors to report medical errors: project DISCLOSE. … Investigators developed a paper-based tool that generated a 2.6-fold increase in reports compared with … Getting doctors to report medical errors: project DISCLOSE. … More Related Resources Qualitative content analysis of coworkers' safety reports

165. Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report. | PSNet
     psnet.ahrq.gov/issue/cultural-issues-related-allegations-bullying-and-harassment-nhs-highland-independent-review
     July 29, 2015 - August 23, 2017 Critical Incident Reviews, Significant Adverse Event Reports and Action … Final Report. … Final Report. … The Report of the Gosport Independent Panel. … Final Report.

166. 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.

167. 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.

168. 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

169. Confronting Racism in Health Care: Moving from Proclamations to New Practices. | PSNet
     psnet.ahrq.gov/issue/confronting-racism-health-care-moving-proclamations-new-practices
     July 31, 2012 - Book/Report Confronting Racism in Health Care: Moving from Proclamations to New Practices … This report summarizes organizational efforts to reduce the impact of systemic racism on patient care … Free full text Related report Save Save to your library Print Download PDF … Citation Related Resources From the Same Author(s) Keeping the Commitment: A Progress … Report on Four Early Leaders in Patient Safety Improvement.

170. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error. | PSNet
     psnet.ahrq.gov/issue/strategies-improving-clinician-psychological-safety-reporting-and-discussing-diagnostic-error
     October 06, 2021 - Book/Report Strategies for Improving Clinician Psychological Safety in Reporting … Psychological safety to report errors stems from a robust safety culture. … August 7, 2024 National Healthcare Quality and Disparities Reports. … August 16, 2023 Final Report on Prioritization of Patient Safety Practices for a New … November 23, 2016 Confidential Physician Feedback Reports: Designing for Optimal Impact

171. 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

172. Conceptual Framework for the International Classification for Patient Safety Version 1.1. Final Technical Report January 2009. | PSNet
     psnet.ahrq.gov/issue/conceptual-framework-international-classification-patient-safety-version-11-final-technical
     December 21, 2005 - Book/Report Conceptual Framework for the International Classification for Patient … Final Technical Report January 2009. … Final Technical Report January 2009. World Alliance for Patient Safety. … Final Technical Report January 2009. World Alliance for Patient Safety. … 2024 View More Related Resources Patient Safety Authority Annual Reports

173. 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

174. Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report. | PSNet
     psnet.ahrq.gov/issue/developing-and-testing-health-care-safety-hotline-prototype-consumer-reporting-system-patient
     October 26, 2016 - Final Report. … Final Report. Schneider EC, Ridgely MS, Quigley DD, et al. … This report describes the development of one such program, the Health Care Safety Hotline. … authors conclude that more research is needed to understand why patients were more likely to access reports … Final Report. Schneider EC, Ridgely MS, Quigley DD, et al.

175. Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients. | PSNet
     psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half-falls-major-injury-and-hospitalization-among
     July 26, 2023 - Book/Report Home Health Agencies Failed To Report Over Half of Falls With Major Injury … Report no. OEI-05-22-00290. … Report no. OEI-05-22-00290. View more articles from the same authors. … Report no. OEI-05-22-00290. … December 4, 2024 Adverse Health Events in Minnesota: Annual Reports.

176. Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients. | PSNet
     psnet.ahrq.gov/issue/revealing-disparities-health-care-workers-observations-discrimination-against-patients
     April 12, 2006 - Book/Report Revealing Disparities: Health Care Workers’ Observations of Discrimination … This report summarizes data examining discriminatory actions observed by health care workers within … September 19, 2024 Keeping the Commitment: A Progress Report on Four Early Leaders in … March 20, 2024 Final Report on Prioritization of Patient Safety Practices for a New Rapid

177. Incidence of Adverse Events in Indian Health Service Hospitals. | PSNet
     psnet.ahrq.gov/issue/incidence-adverse-events-indian-health-service-hospitals
     May 20, 2020 - Book/Report Incidence of Adverse Events in Indian Health Service Hospitals. …  OIG report OEI-06-17-00530. …  OIG report OEI-06-17-00530. … November 8, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care … May 25, 2022 Final Report of the Ockenden Review.

178. AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016. | PSNet
     psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary
     October 23, 2019 - Book/Report AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline … Overall, this report suggests that HAC reduction efforts continue to be successful. … May 1, 2017 AHRQ Health Information Technology Division's 2017 Annual Report. … May 2, 2018 Hospital Survey on Patient Safety Culture: 2018 User Database Report. … January 16, 2025 National Healthcare Quality and Disparities Reports.

179. Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. | PSNet
     psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
     May 01, 2015 - Book/Report Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling … Report No.14-02603-267. … Report No.14-02603-267. … Report No.14-02603-267. … July 26, 2023 Comprehensive Healthcare Inspection Summary Report: Evaluation of Care

180. Risks to Medication Delivery Using Ambulatory Infusion Pumps – Design and Usability in Inpatient Settings. | PSNet
     psnet.ahrq.gov/issue/risks-medication-delivery-using-ambulatory-infusion-pumps-design-and-usability-inpatient
     November 29, 2023 - Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.