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psnet.ahrq.gov/issue/ny-medicaid-ups-ante-refusing-pay-14-never-events-nations-biggest-medicaid-program-could
December 16, 2009 - Newspaper/Magazine Article
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
Citation Text:
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid p…
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psnet.ahrq.gov/issue/organizing-reliability-guide-research-and-practice
April 01, 2020 - Book/Report
Organizing for Reliability: A Guide for Research and Practice.
Citation Text:
Organizing for Reliability: A Guide for Research and Practice. Ramanujam R, Roberts KH, eds. Stanford, CA: Stanford University Press; 2018. ISBN: 9780804793612.
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psnet.ahrq.gov/issue/poll-many-sick-americans-experience-significant-financial-problems-and-report-their-care-not
April 02, 2014 - Book/Report
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.
Citation Text:
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed. Princeton, NJ: Robert Wood Johnson …
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psnet.ahrq.gov/issue/2009-john-m-eisenberg-patient-safety-and-quality-awards
September 24, 2018 - Award Recipient
2009 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
2009 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2009;35(9):583-603.
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psnet.ahrq.gov/issue/err-human-delay-deadly
July 11, 2017 - Book/Report
To Err Is Human — To Delay Is Deadly.
Citation Text:
To Err Is Human — To Delay Is Deadly. Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.
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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…
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psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize
September 23, 2020 - Award Recipient
American Hospital Association-McKesson Quest for Quality Prize.
Citation Text:
American Hospital Association-McKesson Quest for Quality Prize. Jt Comm J Qual Patient Saf. 2006;32(10):541-572.
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psnet.ahrq.gov/issue/2010-john-m-eisenberg-patient-safety-and-quality-awards
September 03, 2011 - Special or Theme Issue
2010 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
2010 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2011;37(5):194-239.
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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.
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psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
May 03, 2023 - Newspaper/Magazine Article
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
Citation Text:
Latest heparin fatality speaks loudly—what have you done to stop the bleeding? ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
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psnet.ahrq.gov/issue/20-years-later-err-leadership-failure
November 30, 2016 - Special or Theme Issue
20 years later: to err is a leadership failure.
Citation Text:
20 years later: to err is a leadership failure. Castellucci M, Meyer H. Modern Healthcare: November 11, 2019;49:18-22;28-30;32-34.
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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 …
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psnet.ahrq.gov/issue/technological-methods-used-prevent-errors-arent-infallible
January 05, 2017 - Newspaper/Magazine Article
Technological methods used to prevent errors aren't infallible.
Citation Text:
Santell JP. Technological methods used to prevent errors aren't infallible. Mater Manag Health Care. 2006;15(12):26-30.
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psnet.ahrq.gov/issue/improving-health-care-work-environment
March 28, 2018 - Special or Theme Issue
Improving the Health Care Work Environment.
Citation Text:
Improving the Health Care Work Environment. Jt Comm J Qual Saf. 2007;33(11 supp):s2-s84.
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psnet.ahrq.gov/issue/eric-cropp-weighs-error-sent-him-prison
May 07, 2018 - Newspaper/Magazine Article
Eric Cropp weighs in on the error that sent him to prison.
Citation Text:
Eric Cropp weighs in on the error that sent him to prison. ISMP Medication Safety Alert! Acute Care Edition. December 3, 2009;14:1-3.
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psnet.ahrq.gov/issue/clinical-reminder-about-safe-use-insulin-vials
June 10, 2018 - Newspaper/Magazine Article
A clinical reminder about the safe use of insulin vials.
Citation Text:
A clinical reminder about the safe use of insulin vials. ISMP Medication Safety Alert! Acute care edition. February 21, 2013;18:1-3.
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psnet.ahrq.gov/issue/medicine-safety-take-care
February 21, 2018 - Book/Report
Medicine Safety: Take Care.
Citation Text:
Medicine Safety: Take Care. Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
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psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
May 30, 2014 - Commentary
The competent surgeon: individual accountability in the era of "systems" failure.
Citation Text:
Whittemore A. The competent surgeon: individual accountability in the era of "systems" failure. Ann Surg. 2009;250(3):357-62. doi:10.1097/SLA.0b013e3181b28c93.
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psnet.ahrq.gov/issue/access-clinical-information-bedside
March 16, 2022 - Book/Report
Access to Clinical Information at the Bedside.
Citation Text:
Access to Clinical Information at the Bedside. Farnborough, UK: Healthcare Safety Investigation Branch; February 2023.
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psnet.ahrq.gov/issue/five-rights-destination-without-map
September 14, 2016 - Newspaper/Magazine Article
The five rights: a destination without a map.
Citation Text:
The five rights: a destination without a map. ISMP Medication Safety Alert! Acute care edition. January 25, 2007.
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