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psnet.ahrq.gov/issue/noise-distraction-interruption-and-safety-hazard
February 01, 2014 - Commentary
Noise: a distraction, interruption, and safety hazard.
Citation Text:
Beyea SC. Noise: a distraction, interruption, and safety hazard. AORN J. 2007;86(2):281-5.
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psnet.ahrq.gov/issue/distractions-interruptions-and-patient-safety
February 01, 2014 - Commentary
Distractions, interruptions, and patient safety.
Citation Text:
Beyea SC. Distractions, interruptions, and patient safety. AORN J. 2007;86(1):109-12.
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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/prescription-drug-time-guarantees-and-their-impact-patient-safety-community-pharmacies
June 10, 2018 - Newspaper/Magazine Article
Prescription drug time guarantees and their impact on patient safety in community pharmacies.
Citation Text:
Prescription drug time guarantees and their impact on patient safety in community pharmacies. ISMP Medication Safety Alert! Acute care edition! Septembe…
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psnet.ahrq.gov/issue/mismatch-made-america
December 31, 2018 - Newspaper/Magazine Article
A mismatch made in America.
Citation Text:
A mismatch made in America. Butcher L. Managed Care. June 2019;28:37-39.
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psnet.ahrq.gov/issue/interview-audrey-nelson-interviewed-steven-berman
January 19, 2022 - Commentary
An interview with Audrey Nelson. Interviewed by Steven Berman.
Citation Text:
Nelson AL. An interview with Audrey Nelson. Interviewed by Steven Berman. Jt Comm J Qual Patient Saf. 2005;31(12):665-670.
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psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols
March 26, 2014 - Newspaper/Magazine Article
Misidentification of alphanumeric symbols.
Citation Text:
Misidentification of alphanumeric symbols. ISMP Medication Safety Alert! Acute care edition. June 5, 2014;19:1-2,4-5.
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/cerner-q-a-final-deck.pdf
June 02, 2025 - Cerner Q&A Session
K a t h y L e e B i s h o p , P T, D P T, C C S ,
F N A P
G u r u P a t e l
Chat Function
2
HOW TO ASK
QUESTIONS
To ask a question or make a comment
open the chat box
Set the TO: field to Everyone so
that we can all see your question
Try the chat function now by
sending a short g…
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www.ahrq.gov/teamstepps-program/curriculum/implement/pre/ready.html
January 01, 2024 - Readiness Assessment
Investing in TeamSTEPPS typically requires one or more identifiable problems that are creating risks to patient safety, care quality, or operational efficiency that an organization or unit agrees they must resolve.
Are You Ready for TeamSTEPPS?
Determining whether your organization or u…
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psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries
August 06, 2016 - Book/Report
Classic
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries.
Citation Text:
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023.
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psnet.ahrq.gov/issue/potassium-may-no-longer-be-stocked-patient-care-units-serious-threats-still-exist
May 02, 2018 - Newspaper/Magazine Article
Potassium may no longer be stocked on patient care units, but serious threats still exist!
Citation Text:
Potassium may no longer be stocked on patient care units, but serious threats still exist! ISMP Medication Safety Alert! Acute care edition. October 4, 200…
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meps.ahrq.gov/data_stats/MEPS_topics.jsp
January 27, 2023 - Medical Expenditure Panel Survey Topics
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An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/declaration-advance-patient-safety
July 12, 2017 - Book/Report
Declaration to Advance Patient Safety.
Citation Text:
Declaration to Advance Patient Safety. National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May 2022.
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psnet.ahrq.gov/issue/understanding-patient-safety-third-edition
November 03, 2015 - Book/Report
Classic
Understanding Patient Safety, Third Edition.
Citation Text:
Understanding Patient Safety, Third Edition. Wachter RM, Gupta K. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249.
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digital.ahrq.gov/ahrq-funded-projects/workshop-interactive-systems-healthcare-2013-bridging-communities
January 01, 2013 - Workshop on Interactive Systems in Healthcare 2013: Bridging Communities
Project Final Report ( PDF , 212.13 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent…
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psnet.ahrq.gov/issue/department-defense-health-care-quality
February 11, 2025 - Book/Report
Department of Defense Health Care Quality.
Citation Text:
Department of Defense Health Care Quality. Washington DC: Office of the Assistant Secretary of Defense; Tricare Management Activity: 2011.
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psnet.ahrq.gov/issue/health-care-simulation-advance-safety-responding-ebola-and-other-threats
September 16, 2015 - Book/Report
Health Care Simulation to Advance Safety: Responding to Ebola and Other Threats.
Citation Text:
Health Care Simulation to Advance Safety: Responding to Ebola and Other Threats. Rockville, MD: Agency for Healthcare Research and Quality; February 2015. AHRQ Publication No. 15-0…
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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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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/friedman-r-et-al-1996
January 01, 1996 - Friedman R et al. 1996 "A telecommunications system for monitoring and counseling patients with hypertension: impact on medication adherence and blood pressure control."
Reference
Friedman R, Kazis L, Jette A, et al. A telecommunications system for monitoring and counseling patients with hypertension:…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/042-ss-training-preop-nasal-iodophor.pptx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention: Targeting SSI
Preoperative Surgical Decolonization
Staff Training: Nasal Decolonization in the Preoperative Area
Nasal Iodophor
(10 Percent Povidone-Iodine)
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, …