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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-17
January 17, 2018 - Pharmacists
Pharmacy
Indwelling Tubes and Catheters
Infusion Pumps
Discontinuities, Gaps
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-21
January 17, 2018 - Pharmacists
Pharmacy
Indwelling Tubes and Catheters
Infusion Pumps
Discontinuities, Gaps
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psnet.ahrq.gov/issue/patient-safety-2
August 31, 2005 - Nurses
Nurse Managers
Plastic Surgery
Medical/Surgical Nursing
Discontinuities, Gaps
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-20
January 17, 2018 - Pharmacists
Hospital Pharmacy
Indwelling Tubes and Catheters
Infusion Pumps
Discontinuities, Gaps
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psnet.ahrq.gov/node/40618/psn-pdf
August 27, 2012 - Despite efforts to promote teamwork
and develop shared tools for communication, there are persistent gaps
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psnet.ahrq.gov/issue/patient-safety-9
August 19, 2015 - Health Care Providers
Health Care Executives and Administrators
Surgery
Discontinuities, Gaps
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psnet.ahrq.gov/node/45302/psn-pdf
November 28, 2016 - patient–clinician collaboration is particularly important for error
disclosure because of the well-documented gaps
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psnet.ahrq.gov/node/41175/psn-pdf
December 31, 2014 - Although
improved discharge summaries address certain gaps in communication, additional strategies are
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psnet.ahrq.gov/node/40946/psn-pdf
January 19, 2012 - investigators found that patients perceived greater team function, but that they
also perceived more safety gaps
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psnet.ahrq.gov/issue/patient-safety-0
February 28, 2015 - More
See More About The Topic
Hospitals
Diagnostic Errors
Discontinuities, Gaps
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psnet.ahrq.gov/issue/closing-gap-and-raising-bar-assessing-board-competency-quality-and-safety
July 20, 2022 - Study
Closing the gap and raising the bar: assessing board competency in quality and safety.
Citation Text:
McGaffigan PA, Ullem BD, Gandhi TK. Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety. Jt Comm J Qual Patient Saf. 2017;43(6):267-274. doi:10.10…
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psnet.ahrq.gov/node/43998/psn-pdf
May 28, 2015 - Bridging the gap between hospital and primary care: the
pharmacist home visit.
May 28, 2015
Ensing HT, Koster ES, Stuijt CCM, et al. Bridging the gap between hospital and primary care: the
pharmacist home visit. Int J Clin Pharm. 2015;37(3):430-4. doi:10.1007/s11096-015-0093-4.
https://psnet.ahrq.gov/issue/bridgin…
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psnet.ahrq.gov/issue/applying-universal-protocol-improve-patient-safety-radiology-services
March 27, 2018 - Providers
Quality and Safety Professionals
Radiology
Identification Errors
Discontinuities, Gaps
-
psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/837038/psn-pdf
May 04, 2022 - Mind the Implementation Gap. The Persistence of
Avoidable Harm in the NHS.
May 4, 2022
London UK: Patient Safety Learning: 2022.
https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…
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psnet.ahrq.gov/node/849606/psn-pdf
May 31, 2023 - The Patient Safety Adoption Framework: a practical
framework to bridge the know-do gap.
May 31, 2023
Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248.
https://psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap
Individual, team, and organization…
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psnet.ahrq.gov/issue/mind-power-gap-how-hierarchical-leadership-healthcare-risk-patient-safety
February 26, 2025 - Commentary
Mind the power gap: how hierarchical leadership in healthcare is a risk to patient safety.
Citation Text:
Kanaris C. Mind the power gap: how hierarchical leadership in healthcare is a risk to patient safety. J Child Health Care. 2023;27(3):319-322. doi:10.1177/1367493523119619…
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psnet.ahrq.gov/node/47456/psn-pdf
April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push
Medication Practices.
April 30, 2019
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
Standardized practices have not been uniformly adopted to support safe IV medicati…
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psnet.ahrq.gov/issue/real-time-debriefing-after-critical-events-exploring-gap-between-principle-and-reality
December 15, 2021 - Review
Emerging Classic
Real-time debriefing after critical events: exploring the gap between principle and reality.
Citation Text:
Arriaga AF, Szyld D, Pian-Smith MCM. Real-time debriefing after critical events: exploring the gap between principle and reality. …
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-13
January 17, 2018 - Pharmacists
Pharmacy
Indwelling Tubes and Catheters
Infusion Pumps
Discontinuities, Gaps