The Health Minister, Dr James Reilly, has said that the fact that nobody was accountable for patients who were left lying on trolleys in corridors for long periods in Tallaght Hospital is "completely unacceptable".
The report results from an investigation following the death on a corridor of a patient awaiting admission in March 2011.
The Health Information and Quality Authority report also revealed patients were at risk while the State failed to hold the hospital to account for the quality and safety of services it provided.
The minister has said that, as recommended in the report, he is putting in place an oversight committee to implement its recommendations.
He also announced that the Chief Medical Officer has referred the report to the Medical Council and An Bord Altranais to ask them to address the issues.
Dr Reilly said: "It is completely unacceptable that there was no clarity as to who was providing medical supervision of these patients. For that reason the Chief Medical Officer has referred the report to the Medical Council and An Bord Altranais to ask them to address the significant issues that arise here."
The Minister offered his condolences to the family involved.
He said: "I want to offer my deepest sympathies to the family concerned. We must never forget that this report is first and foremost about patient safety and that it all began because of the death of a patient on a trolley in a corridor adjacent to the Emergency Department.
"I know that the loved ones involved will find this traumatic and that patients in all of our acute hospitals need the assurance that this matter is being dealt with in an effective way, that lessons have been learned and that Quality Assurance Systems are being put in place across the country”
The statement said that the minister recognised this report as "an important element in driving the Health Reform Programme".
Dr Reilly said: "The HIQA report gives us the template for hospital governance which will be the foundation for the governance of the new hospital groups to be established this year. I have also today approved the HIQA National Standards for Safer Better Healthcare. These standards will support the development of quality safe healthcare services.
The Minister said that he was seeking the greatest collaboration and personal commitment from all involved in the acute hospital system to protect patients and ensure the very best outcomes "despite the challenging economic and financial circumstances we face".
Dr Reilly said that he wanted to acknowledge the contribution of staff at the hospital to implementing change.
He said: "The staff of the hospital have a hugely important role in responding to the challenges ahead, restoring confidence in this hospital and supporting it to achieve its potential. I would also ask the local community to support the staff and the Hospital as it faces the challenges ahead."