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psnet.ahrq.gov/issue/fault-trees-uncover-complex-causes
March 01, 2007 - Newspaper/Magazine Article
Fault trees uncover complex causes.
Citation Text:
Spath P. Fault trees uncover complex causes. Hospital peer review. 2007;32(4):49-52.
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psnet.ahrq.gov/issue/procedures-should-promote-patient-safety
March 01, 2007 - Newspaper/Magazine Article
Procedures should promote patient safety.
Citation Text:
Spath P. Procedures should promote patient safety. Hospital peer review. 2006;31(8):113-6.
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psnet.ahrq.gov/issue/warning-severe-burns-and-permanent-scarring-after-glacial-acetic-acid-995-mistakenly-applied
September 30, 2020 - Press Release/Announcement
Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically.
Citation Text:
Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically. National Alert Net…
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psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs
April 24, 2013 - Book/Report
Freedom to Speak Up: A Review of Whistleblowing in the NHS.
Citation Text:
Freedom to Speak Up: A Review of Whistleblowing in the NHS. Francis R. London, UK: Department of Health; February 2015.
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psnet.ahrq.gov/issue/unintended-exposure-patient-lisa-norris-during-radiotherapy-treatment-beatson-oncology-centre
March 06, 2005 - Book/Report
Unintended Exposure of Patient Lisa Norris During Radiotherapy Treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Citation Text:
Unintended Exposure of Patient Lisa Norris During Radiotherapy Treatment at the Beatson Oncology Centre, Glasgow in January 2006.…
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psnet.ahrq.gov/issue/another-tragic-parenteral-nutrition-compounding-error
June 10, 2018 - Newspaper/Magazine Article
Another tragic parenteral nutrition compounding error.
Citation Text:
Another tragic parenteral nutrition compounding error. ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
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psnet.ahrq.gov/issue/health-care-comes-home-human-factors
June 08, 2011 - Book/Report
Health Care Comes Home: The Human Factors.
Citation Text:
Health Care Comes Home: The Human Factors. Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.
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psnet.ahrq.gov/issue/health-it-safety-center-roadmap
June 29, 2016 - Government Resource
Health IT Safety Center Roadmap.
Citation Text:
Health IT Safety Center Roadmap. RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015.
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psnet.ahrq.gov/issue/heartbroken
January 17, 2024 - Newspaper/Magazine Article
Heartbroken.
Citation Text:
Heartbroken. McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
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psnet.ahrq.gov/issue/human-factors-and-ergonomics-healthcare
September 15, 2021 - Special or Theme Issue
Human Factors and Ergonomics in Healthcare.
Citation Text:
Human Factors and Ergonomics in Healthcare. Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.
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psnet.ahrq.gov/issue/jurans-quality-handbook-5th-ed
October 18, 2017 - Book/Report
Classic
Juran's Quality Handbook. 5th ed.
Citation Text:
Juran's Quality Handbook. 5th ed. Juran JM; Blanton GA. New York: McGraw Hill; 1999. ISBN: 9780071165396.
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psnet.ahrq.gov/issue/cognitive-informatics-reengineering-clinical-workflow-safer-and-more-efficient-care
July 13, 2011 - Book/Report
Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care.
Citation Text:
Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care. Zheng K, Westbrook J, Kannampallil TG, Patel VL, eds. Springer International Publ…
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psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections
June 10, 2018 - Newspaper/Magazine Article
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.
Citation Text:
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. ISMP Medication Safety Alert! Acute care edition. July 26, 2007.
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psnet.ahrq.gov/issue/framework-analysing-risk-and-safety-clinical-medicine
March 05, 2014 - Commentary
Classic
Framework for analysing risk and safety in clinical medicine.
Citation Text:
Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316(7138):1154-7.
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psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
September 29, 2017 - Book/Report
Patient Safety in Ambulatory Settings: Technical Brief.
Citation Text:
Patient Safety in Ambulatory Settings: Technical Brief. Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016.
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psnet.ahrq.gov/issue/medication-related-adverse-outcomes-us-hospitals-and-emergency-departments-2008
September 15, 2010 - Book/Report
Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008.
Citation Text:
Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008. Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency …
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psnet.ahrq.gov/issue/measuring-shared-mental-models-healthcare
June 30, 2019 - Commentary
Measuring shared mental models in healthcare.
Citation Text:
Measuring shared mental models in healthcare. Gisick LM, Webster KL, Keebler JR, et al. J Patient Saf Risk Manag. 2018;23:207–219.
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psnet.ahrq.gov/issue/rethinking-patient-safety
April 13, 2018 - Book/Report
Rethinking Patient Safety.
Citation Text:
Rethinking Patient Safety. Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541.
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psnet.ahrq.gov/issue/safety-medication-use
January 01, 2019 - Book/Report
Safety in Medication Use.
Citation Text:
Safety in Medication Use. Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-42
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Oral Syringes: A Crucial and Economical Risk-Reduction Strategy that has Not Been Fully Utilized; Caution regarding Once-Weekly Levothyroxine; When Drug Strengths Differ by 10-Fold; Lower Colchicine Do…