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  1. Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. | PSNet

    psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
    May 04, 2016 - Book/Report Engineering Patient Safety in Radiation Oncology: University of North … Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary … Report.

  2. Drug Shortages: Public Health Threat Continues, Despite Efforts to Help Ensure Product Availability. | PSNet

    psnet.ahrq.gov/issue/drug-shortages-public-health-threat-continues-despite-efforts-help-ensure-product
    March 19, 2014 - Book/Report Drug Shortages: Public Health Threat Continues, Despite Efforts to Help … View More Related Resources Comprehensive Healthcare Inspection Summary … Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021

  3. 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

  4. 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.

  5. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-among-hospitalized-medicare-patients-epidemiology-and-national-estimates
    April 05, 2016 - More Related Resources National and State Healthcare-Associated Infections Progress … Report. … February 22, 2023 ISMP medication error report analysis.

  6. 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.

  7. Healthcare–Associated Infections (HAI). | PSNet

    psnet.ahrq.gov/issue/healthcare-associated-infections-hai
    September 07, 2016 - 14, 2024 - December 14, 2025 National and State Healthcare-Associated Infections Progress … Report.

  8. Patient Notification Toolkit. | PSNet

    psnet.ahrq.gov/issue/patient-notification-toolkit
    September 07, 2016 - More Related Resources National and State Healthcare-Associated Infections Progress … Report.

  9. Preventing Infections During Cancer Treatment. | PSNet

    psnet.ahrq.gov/issue/preventing-infections-during-cancer-treatment
    September 07, 2016 - More Related Resources National and State Healthcare-Associated Infections Progress … Report.

  10. 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.

  11. 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

  12. 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.

  13. 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

  14. 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

  15. 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

  16. 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.

  17. 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

  18. 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

  19. 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.

  20. 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.
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