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psnet.ahrq.gov/issue/california-mans-painful-and-terrifying-road-monkeypox-diagnosis
August 17, 2022 - Newspaper/Magazine Article
A California man’s ‘painful and terrifying’ road to a Monkeypox diagnosis.
Citation Text:
A California man’s ‘painful and terrifying’ road to a Monkeypox diagnosis. Fortiér J. Kaiser Health News. August 4, 2022.
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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/ehealth-safety-impact-ict-patient-safety-and-risk-management
June 18, 2013 - Book/Report
eHealth for Safety: Impact of ICT on Patient Safety and Risk Management.
Citation Text:
eHealth for Safety: Impact of ICT on Patient Safety and Risk Management. European Commission Information Society and Media. October 2007
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psnet.ahrq.gov/issue/more-half-million-heart-surgery-patients-risk-dangerous-infection
April 22, 2015 - Newspaper/Magazine Article
More than half a million heart surgery patients at risk of a dangerous infection.
Citation Text:
More than half a million heart surgery patients at risk of a dangerous infection. Sun LH.
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psnet.ahrq.gov/issue/medical-error-and-moral-luck
October 02, 2024 - Commentary
Medical error and moral luck.
Citation Text:
Allhoff F. Medical Error and Moral Luck. Kennedy Inst Ethics J. 2019;29(3):187-203. doi:10.1353/ken.2019.0022.
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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/requires-dhss-make-reported-information-about-certain-adverse-events-publicly-available
January 31, 2018 - Legislation/Case Law
Requires DHSS to make reported information about certain adverse events publicly available.
Citation Text:
Requires DHSS to make reported information about certain adverse events publicly available. 212 New Jersey Legislature. Assembly, No. 4327. June 11, 2017.
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psnet.ahrq.gov/issue/organisational-failure-exploratory-study-steel-industry-and-medical-domain
June 02, 2010 - Book/Report
Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain.
Citation Text:
Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain. van Vuuren W. Eindhoven, NL; Eindhoven University of Technology: 1998. ISBN 9038605…
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psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health
July 27, 2011 - Book/Report
The Future of Nursing: Leading Change, Advancing Health.
Citation Text:
The Future of Nursing: Leading Change, Advancing Health. Institute of Medicine. Washington, DC: The National Academies Press: 2011.
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psnet.ahrq.gov/issue/clinician-support-five-years-lessons-learned
March 20, 2017 - Newspaper/Magazine Article
Clinician support: five years of lessons learned.
Citation Text:
Clinician support: five years of lessons learned. Hirschinger LE, Scott SD, Hahn-Cover K. Patient Saf Qual Heathc. April 2015;12:26-31.
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psnet.ahrq.gov/issue/combat-physician-burnout-and-improve-care-fix-electronic-health-record
November 14, 2018 - Newspaper/Magazine Article
To combat physician burnout and improve care, fix the electronic health record.
Citation Text:
To combat physician burnout and improve care, fix the electronic health record. Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
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psnet.ahrq.gov/issue/disclosure-errors-surgical-procedures
April 13, 2022 - Review
Disclosure of errors in surgical procedures.
Citation Text:
Disclosure of errors in surgical procedures. Ryan M, Mekel M, Sinha MS. UptoDate. November 20, 2023.
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psnet.ahrq.gov/issue/out-crisis
March 06, 2005 - Book/Report
Classic
Out of the Crisis.
Citation Text:
Out of the Crisis. Deming WE. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study, 1986. ISBN: 9780911379013.
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psnet.ahrq.gov/issue/independent-double-checks-undervalued-and-misused
July 12, 2023 - Newspaper/Magazine Article
Independent double checks: undervalued and misused.
Citation Text:
Independent double checks: undervalued and misused. ISMP Medication Safety Alert! Acute care edition. June 13, 2013;18:1-4.
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - efforts are part of a larger challenge, many with “zero” as their
goals, such as “Vision Zero” to reduce deaths
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - events associated with failure to rescue following surgical procedures can contribute to preventable deaths
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - matter of speculation—because patients with severe hyperkalemia may die suddenly as outpatients, their deaths
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Duty Hours and Patient Safety
Citation Text:
Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - An estimated 40,000 to 80,000 preventable hospital deaths attributed to medical errors occur annually
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - Every year since 2006, the CMQCC has gathered a multidisciplinary committee to examine maternal deaths … and identify the causes of these deaths.