Your Safety in our Hands in Hospital.

Book/Report

Your Safety in our Hands in Hospital.

April 20, 2023

Patient Safety Surveillance Unit. Department of Health, Perth: Western Australia.

This annual report shares the results of Western Australia's sentinel event reporting program. Medication errors were the highest recorded sentinel event in the latest period. The data is placed in the context of the overall data collected over the last 5 years of the program.

Latest report: free full text (PDF)

Report archive

Related news

Related Resources From the Same Author(s)

Guiding Principles to Achieve Continuity in Medication Management.

December 1, 2022

Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance.

August 20, 2008

Patient Safety.

March 27, 2005

Adverse Events.

August 18, 2010

Indiana Medical Error Reporting System.

March 21, 2007

Serious Reportable Events.

August 27, 2014

The National Healthcare System Action Alliance to Advance Patient Safety.

November 14, 2022 - November 14, 2022

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.

July 23, 2023

Consumer Guide to Adverse Health Events.

February 28, 2015

MRIs and sandbags filled with metal shot.

June 14, 2006

Patient Safety Reporting System.

April 26, 2006

Maryland Hospital Patient Safety Program Annual Report.

September 28, 2023

Advancement toward High Reliability in Healthcare Awards.

September 8, 2010

Professional Conduct Toolkit.

February 9, 2011

Freedom to Speak Up: A Review of Whistleblowing in the NHS.

May 27, 2015

Adverse Health Care Events Reporting System: What Have We Learned?

February 4, 2009

Partnership for Patients.

April 13, 2011

Hospital Performance Report.

October 28, 2021

Hard Truths: the Journey to Putting Patients First.

November 27, 2013

Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections.

July 20, 2011

Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.

March 11, 2015

National Action Plan to Improve Health Literacy.

June 16, 2010

Coding for Success: Simple Technology for Safer Patient Care.

March 14, 2007

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

Serious Reportable Events in Massachusetts.

May 22, 2023

The Report of the Short Life Working Group on Reducing Medication-related Harm.

March 28, 2018

Medicare and Medicaid programs; reform of requirements for long-term care facilities; proposed rule.

July 29, 2015

New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings.

May 21, 2014

Indiana Medical Error Reporting System Final Reports.

September 10, 2008

Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review.

July 25, 2018

Sentinel Event Program.

August 14, 2013

Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities for Improvement.

October 10, 2012

AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).

March 4, 2015

Five Steps to Safer Health Care.

March 27, 2005

Utah DoH Patient Safety Initiatives.

March 6, 2005

Learning Not Blaming.

September 9, 2015

AHRQ Health Services Research Project: Partners Enabling Diagnostic Excellence (R01).

April 3, 2019

Managing the Costs of Clinical Negligence in Trusts.

October 4, 2017

Third Annual Report on Adverse Health Events in Wyoming Healthcare Facilities.

February 11, 2009

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Assessing the Evidence Base for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria.

August 27, 2008

National Action Alliance to Advance Patient Safety Webinar Series.

September 26, 2023 - September 26, 2023

National Action Plan for Adverse Drug Event Prevention.

September 24, 2014

Medication Management: Detailed Use Case.

July 4, 2007

Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.

November 2, 2016

Report of the Independent Inquiry into the Issues Raised by Paterson.

February 19, 2020

Patient Safety and Quality Improvement; Final Rule.

October 22, 2008

Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment.

June 2, 2021

Learning how to learn: compliance with patient safety alerts in the NHS.

August 3, 2005

Best Practices in Developing Proprietary Names for Human Prescription Drug Products Guidance for Industry.

December 23, 2020

Patient Safety Organizations: Hospital Participation, Value, and Challenges.

October 16, 2019

Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies.

January 23, 2008

Best Practices in Developing Proprietary Names for Human Nonprescription Drug Products.

January 13, 2021

Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.

August 9, 2017

Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors: Guidance for Industry.

May 25, 2022

Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.

August 5, 2015

Trends in Nursing Home Deficiencies and Complaints.

October 29, 2008

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.

March 2, 2022

Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.

June 29, 2016

Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

January 9, 2019

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.

August 1, 2012

Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events.

November 16, 2011

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

February 11, 2015

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.

March 19, 2014

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

February 18, 2009

Adverse Events in Hospitals: State Reporting Systems.

January 14, 2009

Adverse Events in Hospitals: Overview of Key Issues.

January 14, 2009

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

November 24, 2010

Adverse Events in Hospitals: Methods for Identifying Events.

March 17, 2010

The Food and Drug Administration's National Drug Code Directory.

September 6, 2006

Adverse Events Toolkit: Medical Record Review Methodology.

July 26, 2023

Adverse Events Toolkit: Clinical Guidance for Identifying Harm

July 19, 2023

Adverse Events in Hospitals: Public Disclosure of Information About Events.

January 20, 2010

Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors.

July 18, 2007

HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics.

October 30, 2019

Effect of patient safety education interventions on patient safety culture of health care professionals: systematic review and meta-analysis.

March 29, 2023

The impact of health system membership on patient safety initiatives.

January 9, 2008

Windows into Safety and Quality in Health Care 2008.

November 12, 2008

Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events.

July 28, 2021

Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000.

March 27, 2005

The London Declaration.

February 22, 2006

Disclosure of Adverse Events to Patients.

November 16, 2005

Reporting of health information technology system-related patient safety incidents: the effects of organizational justice.

October 6, 2021

Training Program for Nurses on Shift Work and Long Work Hours.

October 10, 2021

Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey.

March 22, 2023

Department of Defense (DoD) Patient Safety Program.

May 2, 2007

Quality and Safety of Healthcare in Switzerland.

December 4, 2019

Legislative Report to the General Assembly: Adverse Event Reporting.

January 16, 2013

The impact of health information management professionals on patient safety: a systematic review.

December 22, 2021

Impact of the unit-based patient safety officer.

September 19, 2012

The Canadian Quality and Patient Safety Framework for Health and Social Services.

May 22, 2019

Global Patient Safety Collaborative.

May 16, 2007

Score Your Safety Culture.

March 27, 2005

Hospital Harm Measure.

November 9, 2016

Prevalence and Economic Burden of Medication Errors in the NHS England.

March 14, 2018

Perfecting Detection: Understanding the Source of Harm.

February 21, 2018

WHO Draft Guidelines for Adverse Event Reporting and Learning Systems.

December 21, 2005

Related Resources

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

Interview

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

December 14, 2022

Perspective

Measuring Patient Safety

December 14, 2022

Guiding Principles to Achieve Continuity in Medication Management.

December 1, 2022

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

National Healthcare Quality and Disparities Reports.

November 7, 2022

Independent Neurology Inquiry.

July 20, 2022

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

May 25, 2022

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

October 7, 2021

National and State Healthcare-Associated Infections Progress Report.

October 2, 2021

A Thematic Analysis of HSIB's First 22 Investigations.

September 29, 2021

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

August 20, 2021

Hospital Compare.

May 13, 2021

Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.

January 13, 2021

First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review.

July 22, 2020

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

May 27, 2020

Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.

April 29, 2020

Network of Patient Safety Databases Chartbook, 2019

February 5, 2020

Better Safer Care Victoria.

January 29, 2020

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

January 22, 2020

FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.

April 17, 2019

AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.

February 6, 2019

FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.

November 28, 2018

Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health.

June 6, 2018

Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.

May 16, 2018

The Future of NHS Patient Safety Investigation.

April 4, 2018

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.

December 6, 2017

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Non-Health Care Professionals

Patients

Retained Surgical Instruments and Sponges

Your Safety in our Hands in Hospital.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Your Safety in our Hands in Hospital.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site