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341. The new recommendations on duty hours from the ACGME Task Force. | PSNet
     psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
     July 14, 2021 - extended-duration shifts for first-year residents (as was recommended in a 2008 Institute of Medicine report … October 18, 2017 ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient … November 18, 2020 CLER Report of Findings 2021: Subprotocol for Operative and Procedural … April 14, 2021 National Report of Findings 2016: Issue Brief No. 2: Patient Safety. … July 6, 2011 The response of the APPD, CoPS and AAP to the Institute of Medicine report

342. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
     January 01, 2021 - referring physician – Radiologists are responsible for the production and delivery of radiology reports … – Referring physicians are responsible for obtaining and reading radiology reports 12 “What We … ; only 18.5% reported always reading the report while 2% reported never reading the report • To improve … The Malpractice Liability of Radiology Reports: Minimizing the risk. … Are orthopaedic surgeons reading radiology reports? A Trans-Tasman Survey.

343. Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. | PSNet
     psnet.ahrq.gov/issue/reducing-risk-and-promoting-patient-safety-nih-intramural-clinical-research-draft-report
     November 18, 2020 - Book/Report Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical … Research—Final Report. … September 29, 2017 Should I report? … March 22, 2024 National Healthcare Quality and Disparities Reports. … Final Report.

344. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74705/psn-pdf
     January 26, 2022 - https://psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research … - patient-safety The release of the Institute of Medicine (IOM)’s To Err is Human report in 1999 was … but that the themes of recent research do not necessarily align with the initial focus of the IOM report … https://psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research-patient-safety … https://psnet.ahrq.gov/issue/20-years-after-err-human-bibliometric-analysis-iom-reports-impact-research-patient-safety

345. In Conversation with...Diane Rydrych, MA | PSNet
     psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
     February 26, 2025 - We send out safety alerts when there's an issue we believe they need to be aware of based on the reports … Are there any grounds for skepticism on the accuracy of the reports—perhaps hospitals feel that they … Pennsylvania's system requires reporting of "serious events" and "near misses" and receives nearly 200,000 reports … Your report says, "The information in this report should not be used to compare the safety or quality … Patient Safety Initiatives July 10, 2024 Patient Safety Authority Annual Reports

346. Enhanced free-text search for aggregated medication error report analysis and risk detection. | PSNet
     psnet.ahrq.gov/issue/enhanced-free-text-search-aggregated-medication-error-report-analysis-and-risk-detection
     April 12, 2019 - This study used an enhanced free-text search method to identify the medication error (ME) reports involving … This approach increased the number of identified ME reports involving the specified medications and identified … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

347. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73434/psn-pdf
     June 30, 2021 - clinicians are legally responsible for retaining and being able to produce the radiology reports.5 … revealed that the majority of the 200 orthopedic surgeons surveyed did not routinely read radiology reports … The advent of direct release of reports to patients should also decrease the risk for communication errors … The Malpractice Liability of Radiology Reports: Minimizing the risk. … Are orthopaedic surgeons reading radiology reports? A Trans- Tasman Survey.

348. The Life and Death of Elizabeth Dixon: A Catalyst for Change. | PSNet
     psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change
     November 16, 2022 - The Report of the Independent Medicines and Medical Devices Safety Review. … July 1, 2020 Ockenden Report. … March 20, 2024 National Healthcare Quality and Disparities Reports. … August 10, 2022 Final Report of the Ockenden Review. … The Report of the Independent Medicines and Medical Devices Safety Review.

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/847042/psn-pdf
     April 05, 2023 - The relationship between patient safety culture and the intentions of the nursing staff to report a … The relationship between patient safety culture and the intentions of the nursing staff to report a … https://psnet.ahrq.gov/issue/relationship-between-patient-safety-culture-and-intentions-nursing-staff-report … This mixed- methods study including 199 nurses, who worked in COVID-19 units, found that intent to report … glossary-0#glossary-heading-term-73808 https://psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports

350. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44480/psn-pdf
     October 14, 2015 - Improving radiology report quality by rapidly notifying radiologist of report errors. … Improving Radiology Report Quality by Rapidly Notifying Radiologist of Report Errors. … https://psnet.ahrq.gov/issue/improving-radiology-report-quality-rapidly-notifying-radiologist-report-errors … In this study, researchers designed an algorithm for flagging radiology reports that may contain gender … https://psnet.ahrq.gov/issue/errare-humanum-est-frequency-laterality-errors-radiology-reports

351. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38042/psn-pdf
     June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. … ISMP medication error report analysis. Hosp Pharm. 2010;43(8):618-620. doi:10.1310/hpj4308- 618. … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-28 This monthly selection of medication … error reports addresses examples of unclear dose preparation instructions, potential insulin storage … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-28

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36972/psn-pdf
     June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. … ISMP medication error report analysis. Hosp Pharm. 2010;42(6):498-499. doi:10.1310/hpj4206- 498. … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-14 This monthly selection of medication … error reports includes an error averted because the pharmacist checked the patient's prior prescription … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-14

353. 10-State project to study methods to reduce central line-associated bloodstream infections in hospital ICUs. | PSNet
     psnet.ahrq.gov/issue/10-state-project-study-methods-reduce-central-line-associated-bloodstream-infections-hospital
     October 23, 2019 - Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary … Report. … AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report … December 9, 2009 Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report … Resources AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI: Final Report

354. FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only. | PSNet
     psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only
     February 10, 2021 - 2018 Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—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.

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39470/psn-pdf
     January 09, 2024 - National Healthcare Quality and Disparities Reports. … https://psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-reports In this annual publication … , AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities … Report. … The 2023 report discusses the continued impact of COVID-19 on United States health care delivery.

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74172/psn-pdf
     December 08, 2021 - Differences in safety report event types submitted by graduate medical education trainees compared with … Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compared With … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education … At one children’s hospital, graduate medical education (GME) trainees submitted reports of greater severity … https://psnet.ahrq.gov/issue/differences-safety-report-event-types-submitted-graduate-medical-education-trainees-compared

357. Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace Safety Supplemental Item Set for Hospitals. | PSNet
     psnet.ahrq.gov/issue/updated-results-ahrq-surveys-patient-safety-culture-workplace-safety-supplemental-item-set
     December 11, 2024 - Book/Report Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace … Free full text (PDF) Summary (PDF) Report archive Save Save to your library … Author(s) Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: User Database Report … , 2020 Exploring relationships between hospital patient safety culture and Consumer Reports … March 22, 2024 National Healthcare Quality and Disparities Reports.

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836966/psn-pdf
     April 20, 2022 - Performance variability in perioperative sentinel events: report on a nationwide data set. … Performance variability in perioperative sentinel events: report on a nationwide data set. … https://psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data … performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports … https://psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50795/psn-pdf
     January 15, 2020 - Diagnostic error in the emergency department: learning from national patient safety incident report … Diagnostic error in the emergency department: learning from national patient safety incident report … psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety- incident-report … This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency … psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report

360. Diagnostic stewardship to improve patient outcomes and healthcare-associated infection (HAI) metrics. | PSNet
     psnet.ahrq.gov/issue/diagnostic-stewardship-improve-patient-outcomes-and-healthcare-associated-infection-hai
     May 18, 2022 - September 25, 2024 National and State Healthcare-Associated Infections Progress Report … August 23, 2023 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.