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441. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44300/psn-pdf
     July 29, 2015 - Learning From Serious Failings in Care: Main Report. … July 29, 2015 Short-Life Working Group on Hospital Reports. … https://psnet.ahrq.gov/issue/learning-serious-failings-care-main-report Substantive reports of failures … https://psnet.ahrq.gov/issue/learning-serious-failings-care-main-report https://psnet.ahrq.gov/issue/ … report-mid-staffordshire-nhs-foundation-trust-public-inquiry https://psnet.ahrq.gov/issue/after-mid-staffordshire-acknowledgement-through-learning-improvement

442. Ambulatory Safety and Quality Program: Health IT Portfolio. | PSNet
     psnet.ahrq.gov/issue/ambulatory-safety-and-quality-program-health-it-portfolio-2007-2013
     August 01, 2012 - Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report. … Industrial and Systems Engineering and Health Care: Critical Areas of Research: Final Report … 25, 2010 Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report … August 13, 2014 FDASIA Health IT Report: Proposed Strategy and Recommendations for a

443. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35414/psn-pdf
     May 21, 2014 - Assessment of the National Patient Safety Initiative: Context and Baseline Evaluation Report 1. … psnet.ahrq.gov/issue/assessment-national-patient-safety-initiative-context-and-baseline-evaluation- report … -1 The authors report on the history of Agency for Healthcare Research and Quality's (AHRQ) involvement … This document is the first of four yearly reports funded by AHRQ to assess their work. … /psnet.ahrq.gov/issue/assessment-national-patient-safety-initiative-context-and-baseline-evaluation-report

444. A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. | PSNet
     psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-frequent-even-barcode
     October 22, 2014 - April 16, 2014 ISMP's second QuarterWatch report shows sharp increase in reports of serious … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … May 29, 2019 ISMP medication error report analysis.

445. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40015/psn-pdf
     November 17, 2010 - Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research … Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research … https://psnet.ahrq.gov/issue/medication-prescribing-and-monitoring-errors-primary-care-report-practice … - partner-research This study reports on the development and validation of candidate quality measures … https://psnet.ahrq.gov/issue/medication-prescribing-and-monitoring-errors-primary-care-report-practice-partner-research

446. Medication errors related to product names. | PSNet
     psnet.ahrq.gov/issue/medication-errors-related-product-names
     January 02, 2017 - April 29, 2010 How useful are voluntary medication 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.

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46143/psn-pdf
     June 14, 2017 - Report of the Announced Inspection of Medication Safety at the Midland Regional Hospital Tullamore, … https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital- … tullamore-county Investigation reports help health care organizations identify areas in need of improvement … This report highlights weaknesses in one hospital's medication safety processes and provides suggestions … https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital-tullamore-county

448. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37432/psn-pdf
     November 29, 2009 - The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary … Report. … psnet.ahrq.gov/issue/pennsylvania-learning-exchange-helping-states-improve-and-integrate-patient- safety This report

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38532/psn-pdf
     January 13, 2017 - Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary Report … triggers-and-targeted-injury-detection-systems-tids-expert-panel-meeting- conference-summary This report

450. Multistate point-prevalence survey of health care-associated infections. | PSNet
     psnet.ahrq.gov/issue/multistate-point-prevalence-survey-health-care-associated-infections
     November 14, 2018 - A recent CDC report suggested the potential promise of antibiotic stewardship programs to decrease … May 22, 2024 National and State Healthcare-Associated Infections Progress Report. … November 30, 2023 Hospital Performance Report.

451. Does one size fit all? Developing an evaluation strategy to assess large language models for patient safety event report analysis. | PSNet
     psnet.ahrq.gov/issue/does-one-size-fit-all-developing-evaluation-strategy-assess-large-language-models-patient
     December 07, 2022 - Developing an evaluation strategy to assess large language models for patient safety event report analysis … Developing an evaluation strategy to assess large language models for patient safety event report analysis … Developing an evaluation strategy to assess large language models for patient safety event report analysis … from patient safety event report databases. … Related Resources Enhanced free-text search for aggregated medication error report

452. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43132/psn-pdf
     April 23, 2014 - Hospital Survey on Patient Safety Culture: 2014 User Comparative Database Report. … https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2014-user-comparative-database-report … This annually released report of the AHRQ Hospital Survey on Patient Safety Culture comparative database … The full report contains detailed comparative data for various hospital characteristics (type and size … However, as in prior reports, concerns were voiced about the safety of handoffs.

453. Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. | PSNet
     psnet.ahrq.gov/issue/reducing-and-preventing-adverse-drug-events-decrease-hospital-costs
     March 05, 2013 - Summary, Evidence Report/Technology Assessment. … April 13, 2011 View More Related Resources Final Report on Prioritization … August 9, 2023 Strategies to Improve Patient Safety: Final Report to Congress Required … Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report.

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44483/psn-pdf
     September 09, 2015 - This publication contains the government response to three reports on system failures at the NHS: the … Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe … Common recommendations in the three reports included the need to support open discussions about what … https://psnet.ahrq.gov/issue/learning-not-blaming https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical … https://psnet.ahrq.gov/issue/report-morecambe-bay-investigation https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36048/psn-pdf
     September 27, 2010 - Can technology improve intershift report? What the research reveals. … Can Technology Improve Intershift Report? What the Research Reveals. … https://psnet.ahrq.gov/issue/can-technology-improve-intershift-report-what-research-reveals The authors … review the literature on shift reports and communication of patient information and discuss how to … https://psnet.ahrq.gov/issue/can-technology-improve-intershift-report-what-research-reveals

456. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36068/psn-pdf
     September 28, 2010 - Getting doctors to report medical errors: project DISCLOSE. … Getting doctors to report medical errors: project DISCLOSE. … https://psnet.ahrq.gov/issue/getting-doctors-report-medical-errors-project-disclose This study describes … the implementation of a reporting tool used by physicians to report safety issues during daily rounds … Investigators developed a paper-based tool that generated a 2.6-fold increase in reports compared with

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36704/psn-pdf
     March 28, 2011 - Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. … Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. … https://psnet.ahrq.gov/issue/stopping-error-cascade-report-ameliorators-asips-collaborative The investigators … qualitatively analyzed error reports from the primary care setting in which an error had been caught … https://psnet.ahrq.gov/issue/stopping-error-cascade-report-ameliorators-asips-collaborative

458. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40056/psn-pdf
     November 21, 2016 - Bringing change-of-shift report to the bedside: a patient- and family-centered approach. … Bringing change-of-shift report to the bedside: a patient- and family-centered approach. … https://psnet.ahrq.gov/issue/bringing-change-shift-report-bedside-patient-and-family-centered-approach … This commentary describes nurse change-of-shift reports as a tactic to improve communication with … https://psnet.ahrq.gov/issue/bringing-change-shift-report-bedside-patient-and-family-centered-approach

459. USP initiatives for the safe use of medical gases. | PSNet
     psnet.ahrq.gov/issue/usp-initiatives-safe-use-medical-gases
     July 20, 2022 - This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the  … July 12, 2010 MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication … August 24, 2015 Medmarx Data Report: A Chartbook of Medication-Error Findings from the … June 16, 2019 ISMP medication error report analysis. … November 3, 2015 ISMP medication error report analysis.

460. Sentinel Event Program. | PSNet
     psnet.ahrq.gov/issue/sentinel-event-program
     October 15, 2008 - information about Maine's statewide incident reporting initiative and includes annual sentinel event reports … View More Related Resources Adverse Health Events in Minnesota: Annual Reports … June 4, 2024 National and State Healthcare-Associated Infections Progress Report. … November 30, 2023 Organisation Patient Safety Incident Reports.