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1101. 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

1102. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44636/psn-pdf
      November 04, 2015 - This news article discusses bedside shift reports as a strategy to improve communication among nursing … bedside-shift-shift-handoffs-systematic-review-literature https://psnet.ahrq.gov/issue/making-transition-nursing-bedside-shift-reports

1103. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45581/psn-pdf
      October 19, 2016 - This news article reports how health systems, academic medical centers, and ambulatory care facilities … diagnostic-performance-medical-students-working-individually-or-teams https://psnet.ahrq.gov/issue/using-voluntary-reports-physicians-learn-diagnostic-errors-emergency-medicine

1104. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46628/psn-pdf
      December 18, 2017 - patient-feedback-reporting-tool-opennotes-implications-patient-clinician-safety-and-quality https://psnet.ahrq.gov/issue/confidential-physician-feedback-reports-designing-optimal-impact-performance … https://psnet.ahrq.gov/issue/confidential-physician-feedback-reports-designing-optimal-impact-performance

1105. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38387/psn-pdf
      February 04, 2009 - Obstetrician-gynecologists' opinions about patient safety: costs and liability remain problems; are mandated reports … Obstetrician-gynecologists' opinions about patient safety: costs and liability remain problems; are mandated reports

1106. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39349/psn-pdf
      March 23, 2011 - improvement efforts are often guided by error data that are gathered retrospectively (e.g., incident reports … This study reports on a collaborative process used to prospectively identify safety hazards and improvement

1107. Prohibition of Excessive Overtime for Nurses Act. | PSNet
      psnet.ahrq.gov/issue/prohibition-excessive-overtime-nurses-act
      August 01, 2007 - Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports … View More Related Resources Adverse Health Events in Minnesota: Annual Reports … June 4, 2024 Patient Safety Authority Annual Reports.

1108. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38307/psn-pdf
      January 07, 2009 - national observational study based on retrospective analysis of 12 months of patient safety incident reports … national observational study based on retrospective analysis of 12 months of patient safety incident reports

1109. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38261/psn-pdf
      December 03, 2008 - systematic-assessment-culture-review-tool-assess-errors-clinical-microbiology- laboratory This study discovered that errors from positive culture reports … The authors suggest that careful review of such reports could prevent clinical laboratory errors.

1110. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37511/psn-pdf
      February 06, 2008 - records as a means of identifying adverse events: comparison between medical records and accident reports … records as a means of identifying adverse events: comparison between medical records and accident reports

1111. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40350/psn-pdf
      April 20, 2011 - vulnerabilities to suicide among veterans from the Iraq and Afghanistan conflicts: review of case reports … vulnerabilities to suicide among veterans from the Iraq and Afghanistan Conflicts: review of case reports

1112. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36734/psn-pdf
      March 10, 2011 - integrating-incident-reporting-electronic-patient-record-system This cohort study, conducted in an Australian hospital, reports … integration of incident reporting into routine electronic documentation may help increase physician reports

1113. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47099/psn-pdf
      May 16, 2018 - However, weaknesses in feedback, follow-up, and action resulting from incident reports diminish their … The resulting recommendations suggest the need to improve tracking of incident reports and for clarifying

1114. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39303/psn-pdf
      February 17, 2010 - Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports

1115. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45989/psn-pdf
      June 07, 2017 - Radiologic errors accounted for 7% of all incident reports, of which the most common were incorrect … safety procedures—were judged to be more common than system factors, though only half of the incident reports

1116. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43810/psn-pdf
      March 15, 2016 - partnering-va-stakeholders-develop-comprehensive-patient-safety-data- display-lessons-learned This study reports … medical centers, with input from frontline stakeholders, to integrate data sources including incident reports

1117. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38502/psn-pdf
      May 21, 2009 - hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports … hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports

1118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40427/psn-pdf
      May 04, 2011 - This study reports on the early experience with a medication reconciliation tool for use by primary … Although initial uptake was low, the study reports on many lessons learned through initial implementation

1119. Adverse Health Care Events Reporting System: What Have We Learned? | PSNet
      psnet.ahrq.gov/issue/adverse-health-care-events-reporting-system-what-have-we-learned
      February 28, 2015 - Book/Report Adverse Health Care Events Reporting System: What Have We Learned? … Through a qualitative evaluation of the Minnesota statewide reporting initiative , this report suggests … February 28, 2015 Adverse Health Events in Minnesota: Annual Reports. … 2020 View More Related Resources Patient Safety Authority Annual Reports … December 6, 2017 Serious Adverse Events Reports.

1120. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. | PSNet
      psnet.ahrq.gov/issue/guide-infection-prevention-outpatient-settings-minimum-expectations-safe-care
      June 11, 2014 - Book/Report Guide to Infection Prevention for Outpatient Settings: Minimum Expectations … This report suggests strategies to prevent infections in the outpatient setting and provides links … June 11, 2014 National and State Healthcare-Associated Infections Progress Report. … February 27, 2024 National Healthcare Quality and Disparities Reports. … January 9, 2024 National and State Healthcare-Associated Infections Progress Report.