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601. 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

602. Medication errors: the year in review. | PSNet
     psnet.ahrq.gov/issue/medication-errors-year-review
     May 02, 2018 - Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report. … July 10, 2019 ISMP medication error report analysis.

603. Special Section: IEA Health Care 2021. | PSNet
     psnet.ahrq.gov/issue/special-section-iea-health-care-2021
     August 02, 2010 - Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report. … Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer III Report

604. 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

605. Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety. | PSNet
     psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordination-improve-health-system
     November 29, 2009 - Book/Report Opportunities and Recommendations for State–Federal Coordination to Improve … The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives—Summary … Report.

606. 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.

607. 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

608. 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.

609. 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.

610. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34746/psn-pdf
     July 08, 2016 - https://psnet.ahrq.gov/issue/err-human-building-safer-health-system One measure of the impact of this report … , the first in the series of reports by the Institute of Medicine (IOM) on the quality of health care … in the United States, is that one can still refer to “The IOM Report” and everyone will recognize the … To Err is Human (despite the fact that, as of this writing, the IOM has released approximately 250 reports … Whether one believes these numbers or not, it is clear that the IOM report was essential in placing

611. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45860/psn-pdf
     July 21, 2017 - individual feedback based on questionnaires from frontline nurses followed by goal-setting, versus a summary … report of feedback at the end of the intervention.

612. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41985/psn-pdf
     October 26, 2016 - Legislative Report to the General Assembly: Adverse Event Reporting. … https://psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting This annual … The most recent report discusses an analysis of the 456 incidents submitted in 2015, which represents … Past reports are also available. … https://psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting https://psnet.ahrq.gov

613. Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health. | PSNet
     psnet.ahrq.gov/issue/blind-spots-when-medicine-gets-it-wrong-and-what-it-means-our-health
     April 22, 2016 - Book/Report Blind Spots: When Medicine Gets It Wrong, and What It Means for Our Health … February 15, 2023 ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient

614. Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation. | PSNet
     psnet.ahrq.gov/issue/under-skin-hidden-toll-racism-american-lives-and-health-our-nation
     January 04, 2017 - Book/Report Under the Skin. … Diagnostic Safety and Quality April 26, 2023 Comprehensive Healthcare Inspection Summary … Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021

615. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40341/psn-pdf
     November 30, 2016 - Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. … https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2011-user-comparative-database-report … The full report contains detailed comparative data for various hospital characteristics (type and size … Overall perception of safety culture improved compared with prior reports, and respondents specifically … https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2011-user-comparative-database-report

616. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46764/psn-pdf
     March 28, 2018 - The Report of the Short Life Working Group on Reducing Medication-related Harm. … https://psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm Medication … This report provides recommendations that align with the World Health Organization medication safety … https://psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm https:/ … prevalence-and-economic-burden-medication-errors-nhs-england https://psnet.ahrq.gov/issue/computerized-prescriber-order-entry-related-patient-safety-reports-analysis

617. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37461/psn-pdf
     May 11, 2014 - ISMP medication error report analysis. May 11, 2014 Cohen MR; Smetzer JL. … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-20 This monthly selection of medication … error reports discusses problems related to a lack of standardization in IV dosing and talc misadministration … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-20

618. Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning. | PSNet
     psnet.ahrq.gov/issue/proper-positioning-pharmacy-label-hospira-pca-vials-will-avoid-interference-scanning
     May 05, 2018 - This article reports on an overdose caused by improper label placement on a patient controlled analgesia … May 2, 2018 ISMP's second QuarterWatch report shows sharp increase in reports of serious … June 16, 2019 ISMP medication error report analysis. … January 3, 2017 ISMP medication error report analysis. … December 30, 2014 ISMP medication error report analysis.

619. Sterile water should not be given "freely." | PSNet
     psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
     March 18, 2010 - This article reports on cases of improper IV administration of sterile water, a  high-alert substance … 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.

620. Medication errors associated with documented allergies. | PSNet
     psnet.ahrq.gov/issue/medication-errors-associated-documented-allergies
     March 18, 2010 - This article analyzed reports of medication errors due to patient allergies and found that lack of patient … October 7, 2015 Promote a culture of safety with good catch reports. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … September 1, 2016 ISMP medication error report analysis.