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  1. Sentinel Event Alert. | PSNet

    psnet.ahrq.gov/issue/sentinel-event-alert
    May 30, 2012 - 2012 America's Hospitals: Improving Quality and Safety—The Joint Commission's Annual Report … November 26, 2014 Improving America's Hospitals: The Joint Commission's Annual Report … November 2, 2012 Improving America's Hospitals: The Joint Commission's Report on Quality … December 1, 2010 Improving America's Hospitals: The Joint Commission's Annual Report … of Agreement September 24, 2024 Adverse Health Events in Minnesota: Annual Reports

  2. Advances in Patient Safety: New Directions and Alternative Approaches. | PSNet

    psnet.ahrq.gov/issue/advances-patient-safety-new-directions-and-alternative-approaches
    August 01, 2012 - Book/Report Classic Advances in Patient Safety: New Directions … December 18, 2008 Final Report on Prioritization of Patient Safety Practices for a New … Summary, Evidence Report/Technology Assessment. … View More Related Resources National Healthcare Quality and Disparities Reports … September 29, 2017 High Quality Care for All: NHS Next Stage Review Final Report.

  3. 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

  4. When good doctors go bad: a systems problem. | PSNet

    psnet.ahrq.gov/issue/when-good-doctors-go-bad-systems-problem
    November 02, 2014 - November 2, 2014 Transforming concepts in patient safety: a progress report. … Point, Counterpoint, and Areas of Agreement September 24, 2024 Failure to report

  5. High reliability: truly achieving healthcare quality and safety. | PSNet

    psnet.ahrq.gov/issue/high-reliability-truly-achieving-healthcare-quality-and-safety
    March 18, 2019 - Related Resources From the Same Author(s) Transforming concepts in patient safety: a progress … report. … ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33651/psn-pdf
    June 01, 2007 - We send out safety alerts when there's an issue we believe they need to be aware of based on the reports … But the report gets coverage in our larger Minneapolis and St. … Are there any grounds for skepticism on the accuracy of the reports? … 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

  7. Surveys on Patient Safety Culture. | PSNet

    psnet.ahrq.gov/issue/surveys-patient-safety-culture
    December 24, 2008 - In addition, reports are available that summarize the benchmarking data across cohorts nationwide. … Summary, Evidence Report/Technology Assessment. … Final Report. … 11, 2020 Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report … 12, 2016 Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report

  8. Learn Not Blame. | PSNet

    psnet.ahrq.gov/issue/learn-not-blame
    November 14, 2011 - the Same Author(s) Safety First: Top of Your Board's Agenda: 100 Day Challenge Survey Report … Final Report. … Final Report. June 2, 2010 Making Hospitals Safe for People With Diabetes. … Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports … May 23, 2018 Medical Office Survey on Patient Safety Culture: 2018 User Database Report

  9. Safe Practices for Better Healthcare–2009 Update. | PSNet

    psnet.ahrq.gov/issue/safe-practices-better-healthcare-2009-update
    September 29, 2017 - Final Report October 28, 2020 The Care We Need July 8, 2020 Improving … November 15, 2024 National and State Healthcare-Associated Infections Progress Report

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34804/psn-pdf
    January 05, 2017 - quality-improvement This study determined the rate with which adverse drug events (ADE) resulted in an incident report … and whether differences existed among hospital personnel as to whether an incident report should or … After identifying ADEs in this single-center study, only 6% had a corresponding incident report submitted … administrators, nurse leaders in quality, and staff nurses all agreed that each ADE warranted an incident report … The authors offer a plan to improve reporting systems and provide examples of how past incident reports

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39543/psn-pdf
    May 19, 2010 - Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report. … https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2010-user-comparative-database-report … AHRQ has released database reports yearly since 2007 that present benchmarking data for safety culture … https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2010-user-comparative-database-report … culture-safety https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2007-comparative-database-report

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40776/psn-pdf
    September 14, 2011 - Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report. … ://psnet.ahrq.gov/issue/nursing-home-survey-patient-safety-culture-2011-user-comparative-database- report … Similar to that tool, AHRQ now provides annual comparative reports that present benchmarking data for … https://psnet.ahrq.gov/issue/nursing-home-survey-patient-safety-culture-2011-user-comparative-database-report … https://psnet.ahrq.gov/issue/nursing-home-survey-patient-safety-culture-2011-user-comparative-database-report

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38180/psn-pdf
    December 30, 2014 - ISMP medication error report analysis. December 30, 2014 Smetzer JL, Cohen MR. … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-30 This monthly selection of reports … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-30

  14. 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.

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39577/psn-pdf
    June 09, 2010 - ISMP medication error report analysis. June 9, 2010 Cohen MR, Smetzer JL. …    https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-45 This monthly selection … of error reports discusses incidents involving look-alike drug names, concentration dosage error, and … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-45 https://psnet.ahrq.gov/issue/impact-abbreviations-patient-safety

  16. Physician accused of reusing devices has license suspended. | PSNet

    psnet.ahrq.gov/issue/physician-accused-reusing-devices-has-license-suspended
    December 08, 2010 - This newspaper article reports how a physician reused single-use equipment and put patients at risk for … April 6, 2011 Keeping the Commitment: A Progress Report on Four Early Leaders in Patient

  17. 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.

  18. Origins of and solutions for neonatal medication-dispensing errors. | PSNet

    psnet.ahrq.gov/issue/origins-and-solutions-neonatal-medication-dispensing-errors
    July 21, 2009 - This study reports on a quality improvement effort to eliminate errors due to look-alike, sound-alike … 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.

  19. Drug name confusion: preventing medication errors. | PSNet

    psnet.ahrq.gov/issue/drug-name-confusion-preventing-medication-errors
    January 29, 2018 - This article reports on problems with drug names, the naming process for medications, and both industry … 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.

  20. Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee. | PSNet

    psnet.ahrq.gov/issue/error-avoidance-recommendations-tubing-misconnections-when-using-luer-tip-connectors
    November 21, 2018 - Based on reports received through numerous national organizations, this article provides public policy … May 17, 2023 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.
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