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  1. The high cost of retained surgical items. | PSNet

    psnet.ahrq.gov/issue/high-cost-retained-surgical-items
    February 22, 2023 - Newspaper/Magazine Article The high cost of retained surgical items. Citation Text: The high cost of retained surgical items. Moorehead LD. Outpatient Surgery. April 5, 2023. Copy Citation Save Save to your library Print Download PDF Share …

  2. Sterile compounding tragedy is a symptom of a broken system on many levels. | PSNet

    psnet.ahrq.gov/issue/sterile-compounding-tragedy-symptom-broken-system-many-levels
    February 13, 2019 - Newspaper/Magazine Article Sterile compounding tragedy is a symptom of a broken system on many levels. Citation Text: Sterile compounding tragedy is a symptom of a broken system on many levels. ISMP Medication Safety Alert! Acute Care Edition. October 18, 2012;17:1-4.   Copy C…

  3. Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. | PSNet

    psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections
    June 10, 2018 - Newspaper/Magazine Article Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. Citation Text: Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. ISMP Medication Safety Alert! Acute care edition. July 26, 2007. Copy …

  4. Juran's Quality Handbook. 5th ed. | PSNet

    psnet.ahrq.gov/issue/jurans-quality-handbook-5th-ed
    October 18, 2017 - Book/Report Classic Juran's Quality Handbook. 5th ed. Citation Text: Juran's Quality Handbook. 5th ed. Juran JM; Blanton GA. New York: McGraw Hill; 1999. ISBN: 9780071165396. Copy Citation Save Save to your library Pri…

  5. Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care. | PSNet

    psnet.ahrq.gov/issue/cognitive-informatics-reengineering-clinical-workflow-safer-and-more-efficient-care
    July 13, 2011 - Book/Report Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care. Citation Text: Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care. Zheng K, Westbrook J, Kannampallil TG, Patel VL, eds. Springer International Publ…

  6. Framework for analysing risk and safety in clinical medicine. | PSNet

    psnet.ahrq.gov/issue/framework-analysing-risk-and-safety-clinical-medicine
    March 05, 2014 - Commentary Classic Framework for analysing risk and safety in clinical medicine. Citation Text: Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154-7. Copy Citation Format: …

  7. Medication errors involving healthcare students. | PSNet

    psnet.ahrq.gov/issue/medication-errors-involving-healthcare-students
    December 19, 2016 - Newspaper/Magazine Article Medication errors involving healthcare students. Citation Text: Medication errors involving healthcare students. Hess L, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. March 2016;13:18-23. Copy Citation Save Save to your library …

  8. Technical Series on Safer Primary Care. | PSNet

    psnet.ahrq.gov/issue/technical-series-safer-primary-care
    November 19, 2014 - Book/Report Technical Series on Safer Primary Care. Citation Text: Technical Series on Safer Primary Care. Geneva, Switzerland: World Health Organization; 2016. Copy Citation Save Save to your library Print Download PDF Share Facebook T…

  9. Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. | PSNet

    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…

  10. Handoffs and fumbles. | PSNet

    psnet.ahrq.gov/issue/handoffs-and-fumbles
    June 12, 2007 - Book/Report Handoffs and fumbles. Citation Text: Handoffs and fumbles. Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004. Copy Citation …

  11. The normalization of deviance: what are the perioperative risks? | PSNet

    psnet.ahrq.gov/issue/normalization-deviance-what-are-perioperative-risks
    July 15, 2020 - Commentary The normalization of deviance: what are the perioperative risks? Citation Text: McNamara SA. The normalization of deviance: what are the perioperative risks? AORN J. 2011;93(6):796-801. doi:10.1016/j.aorn.2011.02.009. Copy Citation Format: DOI Google Scholar Pu…

  12. A new frontier in patient safety. | PSNet

    psnet.ahrq.gov/issue/new-frontier-patient-safety
    February 03, 2011 - Commentary A new frontier in patient safety. Citation Text: McCannon J, Berwick DM. A new frontier in patient safety. JAMA. 2011;305(21):2221-2. doi:10.1001/jama.2011.742. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  13. Building accountability through patient safety organizations. | PSNet

    psnet.ahrq.gov/issue/building-accountability-through-patient-safety-organizations
    June 19, 2024 - Commentary Building accountability through patient safety organizations. Citation Text: Ross J. Building accountability through patient safety organizations. J Perianesth Nurs. 2007;22(5):346-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 X…

  14. High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality. | PSNet

    psnet.ahrq.gov/issue/high-reliability-organizations-healthcare-handbook-patient-safety-quality
    July 31, 2019 - Book/Report High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality. Citation Text: High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality. Oster C, Braaten J, eds. Indianapolis, IN: Sigma Theta Tau International; 2016. ISBN: 9781940…

  15. Health literacy and its influence on patient safety. | PSNet

    psnet.ahrq.gov/issue/health-literacy-and-its-influence-patient-safety
    June 19, 2024 - Commentary Health literacy and its influence on patient safety. Citation Text: Ross J. Health Literacy and Its Influence on Patient Safety. Journal of PeriAnesthesia Nursing. 2007;22(3). doi:10.1016/j.jopan.2007.03.005. Copy Citation Format: DOI Google Scholar BibTeX EndN…

  16. A shortage of everything except errors: harm associated with drug shortages. | PSNet

    psnet.ahrq.gov/issue/shortage-everything-except-errors-harm-associated-drug-shortages
    February 13, 2019 - Newspaper/Magazine Article A shortage of everything except errors: harm associated with drug shortages. Citation Text: A shortage of everything except errors: harm associated with drug shortages. ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3. Copy Citation …

  17. Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. | PSNet

    psnet.ahrq.gov/issue/results-ismp-survey-high-alert-medications-differences-between-nursing-pharmacy-and
    March 14, 2023 - Newspaper/Magazine Article Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. Citation Text: Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspe…

  18. Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community. | PSNet

    psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
    September 26, 2016 - Newspaper/Magazine Article Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community. Citation Text: Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community. ISMP Medication Safety Alert! Acute …

  19. Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? | PSNet

    psnet.ahrq.gov/issue/side-tracks-safety-express-interruptions-lead-errors-and-unfinishedwait-what-was-i-doing
    June 10, 2018 - Newspaper/Magazine Article Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? Citation Text: Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? ISMP Medication Safety Alert! Acute care…

  20. Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. | PSNet

    psnet.ahrq.gov/issue/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry-errors
    June 10, 2018 - Newspaper/Magazine Article Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. Citation Text: Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. ISMP Medication Safety Alert! Acute care…
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