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psnet.ahrq.gov/issue/unintended-consequences-new-problems-and-new-solutions
June 27, 2018 - Book/Report
Unintended Consequences: New Problems and New Solutions.
Citation Text:
Unintended Consequences: New Problems and New Solutions. Lehmann CU, Sroussi B, Jaulent MC, eds. Yearb Med Inform. 2016;1:1-271.
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psnet.ahrq.gov/issue/ismp-medication-errors-reporting-program
January 26, 2023 - Measurement Tool/Indicator
ISMP Medication Errors Reporting Program.
Citation Text:
ISMP Medication Errors Reporting Program. Institute for Safe Medication Practices
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psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry
September 29, 2021 - Commentary
Comparing perspectives on organisational silence: an analysis of the Gosport inquiry.
Citation Text:
Comparing perspectives on organisational silence: an analysis of the Gosport inquiry. Powell M. J Health Org Manag. 2023;37(1):67-83.
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psnet.ahrq.gov/issue/hazards-tied-medical-records-rush
July 26, 2011 - Newspaper/Magazine Article
Hazards tied to medical records rush.
Citation Text:
Hazards tied to medical records rush. Rowland C.
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psnet.ahrq.gov/issue/naval-aviation-safety-and-its-application-medicine
June 01, 2016 - Newspaper/Magazine Article
Naval aviation safety and its application to medicine.
Citation Text:
Naval aviation safety and its application to medicine. Harmon KT. Patient Saf Qual Healthc. March/April 2006.
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psnet.ahrq.gov/issue/improving-rapid-response-systems-progress-issues-and-future-directions
January 26, 2022 - Meeting/Conference Proceedings
Improving rapid response systems: progress, issues, and future directions.
Citation Text:
Ovretveit J, Suffoletto J-A. Improving rapid response systems: progress, issues, and future directions.
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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/sentinel-event-statistics-1995-2019
February 28, 2018 - Measurement Tool/Indicator
Sentinel Event Data Summary.
Citation Text:
Sentinel Event Data Summary. Joint Commission.
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psnet.ahrq.gov/issue/epidural-iv-route-mix-ups-reducing-risk-deadly-errors
May 02, 2018 - Newspaper/Magazine Article
Epidural-IV route mix-ups: reducing the risk of deadly errors.
Citation Text:
Epidural-IV route mix-ups: reducing the risk of deadly errors. ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
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psnet.ahrq.gov/issue/geriatric-medication-reconciliation-home-setting
September 01, 2021 - Newspaper/Magazine Article
Geriatric medication reconciliation in the home setting.
Citation Text:
Geriatric medication reconciliation in the home setting. Taylor K. American Nurse J. 2021;16(7):14-17.
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psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-and-recommendations-independent-review-maternity-services
April 27, 2022 - Book/Report
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.
Citation Text:
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at …
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psnet.ahrq.gov/issue/community-pharmacy-survey-patient-safety-culture
October 23, 2019 - Measurement Tool/Indicator
Community Pharmacy Survey on Patient Safety Culture.
Citation Text:
Community Pharmacy Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; July 2018.
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psnet.ahrq.gov/issue/ismp-survey-provides-insights-preparation-and-admixture-practices-outside-pharmacy
December 02, 2020 - Newspaper/Magazine Article
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.
Citation Text:
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. ISMP Medication Safety Alert! Acute care edition. November 5…
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psnet.ahrq.gov/issue/pharmacist-staffing-and-use-technology-small-rural-hospitals-implications-medication-safety
August 01, 2012 - Book/Report
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.
Citation Text:
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety. Casey MM, Moscovice I, Davidson G. Minn…
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psnet.ahrq.gov/issue/first-annual-review-data-submitted-ismp-national-vaccine-errors-reporting-program-verp
June 10, 2018 - Newspaper/Magazine Article
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).
Citation Text:
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). ISMP Medication Safety Alert! Acute Care Editi…
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psnet.ahrq.gov/issue/safety-still-compromised-computer-weaknesses
September 14, 2016 - Newspaper/Magazine Article
Safety still compromised by computer weaknesses.
Citation Text:
Safety still compromised by computer weaknesses. ISMP Medication Safety Alert! Acute Care Edition. August 25, 2005;10:1-3.
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psnet.ahrq.gov/node/49410/psn-pdf
July 01, 2003 - A Little Shuteye
July 1, 2003
Farion KJ. A Little Shuteye. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/little-shuteye
The Case
A 3-year-old boy was seen in urgent care for a superficial laceration above the left eyebrow. The
pediatrician had heard of the availability of topical skin adhesive that can be…
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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psnet.ahrq.gov/node/33781/psn-pdf
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
In Conversation With… Brian Jarman, PhD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
Editor's note: Sir Brian Jarman is an emeritus professor at Imperial College School of Medicine and a
past president of the Britis…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2025…