Department of Defense Health Care Quality.

Book/Report

Department of Defense Health Care Quality.

January 10, 2007

Washington DC: Office of the Assistant Secretary of Defense; Tricare Management Activity: 2011.

This report series discusses activities and achievements of the U.S. Department of Defense's health care program in including culture of safety development, error and near miss report analysis, and medical team coordination. There were 5 editions of the report produced between 2005-2011.

Free full text

Report archive

Related Resources From the Same Author(s)

VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.

November 9, 2011

Serious Reportable Events in Healthcare—2011 Update.

May 30, 2007

The Future of Nursing: Leading Change, Advancing Health.

March 31, 2011

The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety.

October 19, 2011

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

November 16, 2011

The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.

February 9, 2011

Professional Conduct Toolkit.

February 9, 2011

A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System.

May 11, 2011

Department of Defense (DoD) Patient Safety Program.

May 2, 2007

Health Care Comes Home: The Human Factors.

August 3, 2011

Coordination Between Emergency and Primary Care Physicians.

April 20, 2011

Health IT and Patient Safety: Building Safer Systems for Better Care.

November 16, 2011

Safety Assurance Factors for EHR Resilience: SAFER Guides.

January 29, 2014

Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary.

July 27, 2011

Ensuring Healthcare Safety Throughout the COVID-19 Pandemic.

June 10, 2020

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

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

July 20, 2011

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

January 4, 2006

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

December 12, 2018

Health IT Patient Safety Action and Surveillance Plan.

July 17, 2013

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.

July 5, 2006

Health IT Safety Center Roadmap.

July 29, 2015

Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.

March 13, 2019

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.

March 9, 2016

Approaches and Challenges to Electronically Matching Patients' Records Across Providers.

March 6, 2019

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

September 5, 2012

Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.

July 11, 2018

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

May 16, 2018

Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

August 15, 2018

Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm.

November 22, 2017

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

December 6, 2017

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

November 16, 2022

Patient Options for Safe and Effective Disposal of Unused Opioids.

September 25, 2019

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Medicare's Oversight of Ambulatory Surgery Centers Report.

October 23, 2019

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

April 29, 2020

Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.

October 15, 2008

Hospital Reporting of Deaths Related to Restraint and Seclusion.

September 27, 2006

Nursing Home Complaint Investigations.

September 20, 2006

The Uneven Burden of Maternal Mortality in the U.S.

August 10, 2022

Patient Safety Act.

February 10, 2010

Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.

May 4, 2016

Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.

July 20, 2016

Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

February 24, 2016

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events.

September 9, 2015

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

DOD and VA Health Care: Medication Needs During Transitions May Not Be Managed for All Servicemembers.

November 28, 2012

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.

March 19, 2014

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

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

February 19, 2014

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

April 22, 2020

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

January 19, 2022

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

May 27, 2020

Medication Management: Detailed Use Case.

July 4, 2007

Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections.

April 30, 2008

First do no harm.

March 23, 2011

Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention.

September 18, 2013

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.

August 15, 2012

National Action Plan for Adverse Drug Event Prevention.

September 24, 2014

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

September 30, 2020

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

February 1, 2023

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

May 25, 2022

Addressing Health Worker Burnout.

June 8, 2022

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

November 8, 2023

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

November 13, 2013

VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.

January 15, 2014

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

August 2, 2023

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota.

January 29, 2020

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Complexity and the Adoption of Innovation in Health Care.

March 6, 2005

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

August 9, 2017

Trends in Nursing Home Deficiencies and Complaints.

October 29, 2008

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

January 23, 2008

Medicare proposes new hospital value-based purchasing program.

January 19, 2011

Clinician Well-Being Knowledge Hub.

April 4, 2018

NAM Action Collaborative on Clinician Well-Being and Resilience.

February 15, 2017

Patient Safety Measures.

December 11, 2013

Diagnostic Safety and Quality Webinar Series: Overview and Implications for Hospitals.

November 28, 2023 - November 28, 2023

Related Resources

Interview

In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0

February 28, 2024

Perspective

Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training

February 28, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

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

June 14, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

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

November 16, 2022

Independent Neurology Inquiry.

July 20, 2022

Declaration to Advance Patient Safety.

May 25, 2022

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

June 16, 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

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

October 7, 2020

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

October 7, 2020

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

July 22, 2020

Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries.

July 15, 2020

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

April 29, 2020

Patient Safety Improvement Act of 2020.

March 25, 2020

Network of Patient Safety Databases Chartbook, 2019

February 5, 2020

Evidence Brief: Implementation of High Reliability Organization Principles.

July 24, 2019

The NHS Patient Safety Strategy.

July 24, 2019

Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.

June 26, 2019

Safer Hospital Care: Strategies for Continuous Innovation, Second Edition.

May 16, 2019

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

January 9, 2019

Hospital Survey on Patient Safety Culture: 2018 User Database Report.

April 4, 2018

The Future of NHS Patient Safety Investigation.

April 4, 2018

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

December 6, 2017

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

See More About The Topic

Health Care Executives and Administrators

Policy Makers

Medicine

Near Miss

Quality Improvement Strategies