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psnet.ahrq.gov/issue/tragic-error-neuromuscular-blocker-should-prompt-risk-assessment-all-hospitals
November 16, 2015 - Newspaper/Magazine Article
Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.
Citation Text:
Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. ISMP Medication Safety Alert! Acute Care Edition. December 18, 2014;19…
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psnet.ahrq.gov/issue/iowans-views-medical-errors-iowa-patient-safety-study
October 23, 2019 - Book/Report
Iowans' Views on Medical Errors: Iowa Patient Safety Study.
Citation Text:
Iowans' Views on Medical Errors: Iowa Patient Safety Study. Clive, IA: Heartland Health Research Institute; January 7, 2018.
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psnet.ahrq.gov/issue/dont-abandon-second-victims-medical-errors
September 26, 2017 - Commentary
Don't abandon the "second victims" of medical errors.
Citation Text:
Smetzer JL. Don't abandon the "second victims" of medical errors. Nursing (Brux). 2012;42(2):54-8. doi:10.1097/01.NURSE.0000410310.38734.e0.
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psnet.ahrq.gov/issue/ask-or-not-ask-results-formative-assessment-video-empowering-patients-ask-their-health-care
June 28, 2013 - Image/Poster
To ask or not to ask?: the results of a formative assessment of a video empowering patients to ask their health care providers to perform hand hygiene.
Citation Text:
To ask or not to ask?: the results of a formative assessment of a video empowering patients to ask their h…
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psnet.ahrq.gov/issue/will-my-patient-fall
March 13, 2013 - Review
Will my patient fall?
Citation Text:
Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007;297(1):77-86.
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psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
September 26, 2017 - Commentary
Unlabeled containers lead to patient's death.
Citation Text:
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-44
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Neuromuscular Blocker Mix-up in the Pharmacy; ISMP and Doctor's Digest Launch New iPhone Application; “UD” for “Ut Dictum”—an Ambiguous and Dangerous Abbreviation; Order by Metric Weight, Not Volume.…
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psnet.ahrq.gov/issue/focusing-health-care-safety
January 16, 2008 - Special or Theme Issue
Focusing on Health Care Safety.
Citation Text:
Focusing on Health Care Safety. IEEE Transactions on Systems, Man, and Cybernetics, Part A: Systems and Humans. 2004;34(601):689-778.
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psnet.ahrq.gov/issue/teamstepps-diagnosis-improvement
July 17, 2024 - Toolkit
TeamSTEPPS for Diagnosis Improvement.
Citation Text:
TeamSTEPPS for Diagnosis Improvement.
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psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
June 13, 2018 - Toolkit
ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.
Citation Text:
ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2018.
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psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
May 11, 2017 - Organizational Policy/Guidelines
ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults.
Citation Text:
ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. Horsham, PA: Institute for Safe Medication Practices; May 2017.
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-final-rule
December 24, 2008 - Government Resource
Patient Safety and Quality Improvement; Final Rule.
Citation Text:
Patient Safety and Quality Improvement; Final Rule. US Department of Health and Human Services; Agency for Healthcare Research and Quality; Federal Register. November 21, 2008;73:70731-70814.
C…
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psnet.ahrq.gov/issue/oral-chemotherapy-not-just-ordinary-pill
May 05, 2018 - Newspaper/Magazine Article
Oral chemotherapy: not just an ordinary pill.
Citation Text:
Oral chemotherapy: not just an ordinary pill. ISMP Canada. SafeMedicineUse. August 19, 2015;6:1-2.
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psnet.ahrq.gov/issue/advances-patient-safety-new-directions-and-alternative-approaches
August 01, 2012 - Book/Report
Classic
Advances in Patient Safety: New Directions and Alternative Approaches.
Citation Text:
Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publicatio…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-43
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Safer Connectors in the United Kingdom; Value of the Independent Double-Check; Medication Errors Column in 35th Year. Hosp Pharm. 2010;45(3). doi:10.1310/hpj4503-191.
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psnet.ahrq.gov/issue/nhs-staff-cried-safety-interviews-says-watchdog
August 30, 2023 - Newspaper/Magazine Article
NHS staff cried in safety interviews, says watchdog.
Citation Text:
NHS staff cried in safety interviews, says watchdog. Reed J. BBC. February 27, 2023.
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
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psnet.ahrq.gov/print/pdf/node/842920
December 14, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Errors Case Studies
Curated Library
Web M&Ms
A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, and Sanjat Kanjilal, MD, MPH | April 28, 2021
A pregnant patient was admitted for…
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psnet.ahrq.gov/node/44024/psn-pdf
October 13, 2015 - Cultivating a culture of medication safety in prelicensure
nursing students.
October 13, 2015
Bush PA, Hueckel RM, Robinson D, et al. Cultivating a Culture of Medication Safety in Prelicensure
Nursing Students. Nurse Educ. 2015;40(4):169-73. doi:10.1097/NNE.0000000000000148.
https://psnet.ahrq.gov/issue/cultivatin…
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psnet.ahrq.gov/node/46973/psn-pdf
June 25, 2018 - Balancing innovation and safety when integrating digital
tools into health care.
June 25, 2018
Auerbach AD, Neinstein A, Khanna R. Balancing Innovation and Safety When Integrating Digital Tools Into
Health Care. Ann Intern Med. 2018;168(10):733-734. doi:10.7326/M17-3108.
https://psnet.ahrq.gov/issue/balancing-inno…