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441. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36100/psn-pdf
     July 12, 2006 - Scathing report on Kaiser kidney program. … https://psnet.ahrq.gov/issue/scathing-report-kaiser-kidney-program-transplant-delays-assailed-medicare … - threatens-end This article reports on a Centers for Medicare & Medicaid Services report that details … https://psnet.ahrq.gov/issue/scathing-report-kaiser-kidney-program-transplant-delays-assailed-medicare-threatens-end … https://psnet.ahrq.gov/issue/scathing-report-kaiser-kidney-program-transplant-delays-assailed-medicare-threatens-end

442. 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.

443. 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.

444. 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.

445. 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.

446. 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

447. 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

448. 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

449. 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

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40005/psn-pdf
     November 17, 2010 - Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report. … issue/incorporating-health-information-technology-workflow-redesign-request- information-summary The report

451. 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

452. Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization (PSO). | PSNet
     psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization-pso
     December 24, 2008 - More Related Resources National and State Healthcare-Associated Infections Progress … Report. … November 30, 2023 Hospital Performance Report.

453. 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.

454. 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.

455. 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

456. 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

457. 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

458. 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

459. Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention. | PSNet
     psnet.ahrq.gov/issue/advancing-medication-safety-establishing-national-action-plan-adverse-drug-event-prevention
     September 29, 2017 - safety reports and a call to action. … 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.

460. Don't underestimate the impact of change on risk potential. | PSNet
     psnet.ahrq.gov/issue/dont-underestimate-impact-change-risk-potential
     May 02, 2018 - May 2, 2018 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. … June 16, 2019 ISMP medication error report analysis.