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psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route
December 19, 2016 - Government Resource
Oral medications inadvertently given via the intravenous route.
Citation Text:
Oral medications inadvertently given via the intravenous route. Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
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psnet.ahrq.gov/issue/hospitals-tally-their-avoidable-mistakes
October 23, 2019 - Newspaper/Magazine Article
Hospitals tally their avoidable mistakes.
Citation Text:
Hospitals tally their avoidable mistakes. Rein L. Washington Post. July 21, 2009:E1.
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psnet.ahrq.gov/issue/practitioners-anticipate-punitive-action-licensing-bodies
June 01, 2022 - Newspaper/Magazine Article
Practitioners anticipate punitive action from licensing bodies.
Citation Text:
Practitioners anticipate punitive action from licensing bodies. ISMP Medication Safety Alert! Acute care edition. May 19, 2005.
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psnet.ahrq.gov/issue/teaching-clinical-reasoning
August 20, 2018 - Book/Report
Teaching Clinical Reasoning.
Citation Text:
Teaching Clinical Reasoning. Trowbridge RL Jr, Rencic JJ, Durning SJ, eds. Philadelphia, PA: American College of Physicians; 2015. ISBN: 9781938921056.
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psnet.ahrq.gov/issue/doctor-doesnt-listen-her-media-starting
August 12, 2020 - Newspaper/Magazine Article
The doctor doesn't listen to her. But the media is starting to.
Citation Text:
The doctor doesn't listen to her. But the media is starting to. Fetters A. The Atlantic. August 10, 2018.
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psnet.ahrq.gov/issue/five-years-experience-using-front-line-ownership-improve-healthcare-quality-and-safety
March 09, 2016 - Special or Theme Issue
Five Years of Experience Using Front-line Ownership to Improve Healthcare Quality and Safety.
Citation Text:
Five Years of Experience Using Front-line Ownership to Improve Healthcare Quality and Safety. Healthc Pap. 2017;17:1-61.
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psnet.ahrq.gov/issue/jcaho-proposal-patient-centered-care-brings-concept-mainstream-healthcare-settings
September 03, 2008 - Commentary
JCAHO proposal for patient-centered care brings concept to mainstream healthcare settings.
Citation Text:
JCAHO proposal for patient-centered care brings concept to mainstream healthcare settings. ECRI. Risk Management Reporter. June 2005.
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psnet.ahrq.gov/issue/harm-free-care
April 15, 2020 - Multi-use Website
Harm Free Care.
Citation Text:
Harm Free Care. National Health Service.
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May 9, 2012 …
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psnet.ahrq.gov/issue/pharmaceutical-industry-and-medical-device-companies-part-solution
November 29, 2017 - Newspaper/Magazine Article
Pharmaceutical industry and medical device companies: part of the solution?
Citation Text:
Pharmaceutical industry and medical device companies: part of the solution? ISMP Medication Safety Alert! Acute Care Edition. November 16, 2006.
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psnet.ahrq.gov/issue/get-me-out-alive
September 12, 2016 - Newspaper/Magazine Article
Get me out alive.
Citation Text:
Get me out alive. Feldman R. Washington Post. May 2, 2006.
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psnet.ahrq.gov/issue/patient-stories-2013-time-change
November 14, 2011 - Book/Report
Patient Stories 2013: Time for Change.
Citation Text:
Patient Stories 2013: Time for Change. Harrow, Middlesex, UK: The Patients Association; 2013.
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psnet.ahrq.gov/issue/vanderbilt-center-patient-and-professional-advocacy
March 02, 2022 - Multi-use Website
Vanderbilt Center for Patient and Professional Advocacy.
Citation Text:
Vanderbilt Center for Patient and Professional Advocacy. 2135 Blakemore Ave, Nashville, TN 37212. Phone: (615) 343-4500
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psnet.ahrq.gov/issue/why-hospitals-should-fly-ultimate-flight-plan-patient-safety-and-quality-care
December 19, 2018 - Book/Report
Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care.
Citation Text:
Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058.
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - A Fumbled Handoff to Inpatient Rehab
Citation Text:
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/node/866848/psn-pdf
September 25, 2024 - In Conversation with Eric Thomas about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce
Preventable Harms – Point, Counterpoint, and Areas of Agreement. …
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - ineffective communication and collaboration and their effect on information transfer, assumption of and accountability … the workforce, we understand that everyone on the health care team needs to take responsibility and accountability
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - ineffective communication and collaboration and their effect on information transfer, assumption of and accountability … the workforce, we understand that everyone on the health care team needs to take responsibility and accountability
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - Expectations for unit safety behavior and accountability for use of standard safety tools (readback, … approach is reinforced through servant leadership fostering and environment of psychological safety and accountability
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - In Conversation With... James Augustine, MD
July 28, 2021
In Conversation With.. James Augustine, MD. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-james-augustine-md
Editor’s Note: James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care
Solutions where he p…