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psnet.ahrq.gov/issue/nearly-all-hospital-pharmacists-say-drug-shortages-are-negatively-impacting-care-third-say
September 15, 2021 - Newspaper/Magazine Article
Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’
Citation Text:
Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’ McPhillips…
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psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient
March 14, 2023 - Newspaper/Magazine Article
Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.
Citation Text:
Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. ISMP Medication Safety Alert! Acute care editi…
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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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psnet.ahrq.gov/issue/piece-my-mind-how-many-have-you-done
December 01, 2004 - Commentary
A piece of my mind. How many have you done?
Citation Text:
Reisman A. A PIECE OF MY MIND. How Many Have You Done? JAMA. 2016;316(5):491. doi:10.1001/jama.2016.1996.
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psnet.ahrq.gov/issue/medical-error-disclosure-gap-between-attitude-and-practice
November 13, 2024 - Study
Medical error disclosure: the gap between attitude and practice.
Citation Text:
Ghalandarpoorattar SM, Kaviani A, Asghari F. Medical error disclosure: the gap between attitude and practice. Postgrad Med J. 2012;88(1037):130-3. doi:10.1136/postgradmedj-2011-130118.
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psnet.ahrq.gov/periodic-issue/periodic-issue-415
November 29, 2023 - alerts, assigning one prescriber to oversee medication reconciliation, and instituting a policy on hold
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psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - The Case A 70-year-old man without documented past psychiatric history was placed on an involuntary hold … He was placed on an extended involuntary hold on day 3.
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psnet.ahrq.gov/issue/making-business-case-quality-and-safety
January 19, 2022 - Commentary
Making the business case for quality and safety.
Citation Text:
Shah RK, Reinhart R, Cronin J. Making the business case for quality and safety. Otolaryngol Clin North Am. 2022;55(1):105-113. doi:10.1016/j.otc.2021.07.008.
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psnet.ahrq.gov/issue/unexpected-intraoperative-patient-death-imperatives-family-and-surgeon-centered-care
August 04, 2021 - Commentary
Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care.
Citation Text:
Taylor D, Hassan MA, Luterman A, et al. Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care. Arch Surg. 2008;143(1):87-92. do…
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psnet.ahrq.gov/issue/safety-considerations-challenges-when-using-smart-infusion-pumps
October 26, 2022 - Newspaper/Magazine Article
Safety considerations for challenges when using smart infusion pumps.
Citation Text:
Safety considerations for challenges when using smart infusion pumps. ISMP Medication Safety Alert! Acute care edition. October 20, 2022;20(21):1-5.
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psnet.ahrq.gov/issue/preventing-errors-when-preparing-and-administering-medications-enteral-feeding-tubes
November 30, 2016 - Newspaper/Magazine Article
Preventing errors when preparing and administering medications via enteral feeding tubes.
Citation Text:
Preventing errors when preparing and administering medications via enteral feeding tubes. ISMP Medication Safety Alert! Acute care edition. November 17, 202…
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psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
July 08, 2015 - Newspaper/Magazine Article
The absence of a drug–disease interaction alert leads to a child's death.
Citation Text:
The absence of a drug–disease interaction alert leads to a child's death. ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
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psnet.ahrq.gov/issue/what-about-doctors-impact-medical-errors-0
December 15, 2014 - Commentary
What about doctors? The impact of medical errors.
Citation Text:
Abd Elwahab S, Doherty E. What about doctors? The impact of medical errors. The Surgeon. 2014;12(6). doi:10.1016/j.surge.2014.06.004.
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - Update on Safety Culture
August 22, 2013
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/update-safety-culture
Perspective
Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians
treat each other with r…
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psnet.ahrq.gov/issue/accuracy-computer-aided-diagnosis-melanoma-meta-analysis
June 26, 2019 - Review
Emerging Classic
Accuracy of computer-aided diagnosis of melanoma: a meta-analysis.
Citation Text:
Dick V, Sinz C, Mittlböck M, et al. Accuracy of Computer-Aided Diagnosis of Melanoma. JAMA Dermatol. 2019;155(11):1291-1299. doi:10.1001/jamadermatol.2019.1…
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psnet.ahrq.gov/issue/patient-safety-what-about-patient
January 22, 2025 - Commentary
Classic
Patient safety: what about the patient?
Citation Text:
Vincent C, Coulter A. Patient safety: what about the patient? Qual Saf Health Care. 2002;11(1):76-80.
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psnet.ahrq.gov/node/33837/psn-pdf
July 01, 2017 - It's not easy to hold hospitals legally accountable for care, and when the error occurs because
of an … As I alluded to earlier, right now it's very difficult to hold health care
institutions accountable … so unless the failure on the part of the hospital itself can be identified, it's very
difficult to hold
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psnet.ahrq.gov/information/Editor
February 26, 2021 - Editorial Team
Patrick Romano, MD, MPH, Co-Editor in Chief
Dr. Romano, Professor of General Medicine and Pediatrics, is a physician-epidemiologist and health services researcher in the Divisions of General Medicine and General Pediatrics, the Center for Healthcare Policy and Research, and the Graduate Groups …
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
November 11, 2020 - Commentary
Five strategies for a safer EHR modernization journey.
Citation Text:
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
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