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Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. | PSNet

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…

Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. | PSNet

psnet.ahrq.gov/issue/survey-suggests-possible-downward-trend-identifying-key-drugsdrug-classes-high-alert

July 30, 2014 - Newspaper/Magazine Article Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. Citation Text: Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. ISMP Medication Safety Alert! Acute …

With oral chemotherapy, we simply must do better! | PSNet

psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better

February 13, 2019 - Newspaper/Magazine Article With oral chemotherapy, we simply must do better! Citation Text: With oral chemotherapy, we simply must do better! ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4. Copy Citation Save Save to your library Prin…

Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. | PSNet

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March 15, 2022 - Newspaper/Magazine Article Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. Citation Text: Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. ISMP Medication Safety Alert! Acute care edition. March 27, 2014;19:1-5. Copy …

Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. | PSNet

psnet.ahrq.gov/issue/survey-shows-room-improvement-two-new-ismp-targeted-medication-safety-best-practices

February 12, 2020 - Newspaper/Magazine Article Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. Citation Text: Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. ISMP Medication Safety Alert! Acute care edition. July 3…

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error | PSNet

psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error

February 10, 2021 - Newspaper/Magazine Article Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error Citation Text: Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. …

Salzburg Global Seminar Session 565—Better Health Care: How Do We Learn About Improvement? | PSNet

psnet.ahrq.gov/issue/salzburg-global-seminar-session-565-better-health-care-how-do-we-learn-about-improvement

April 27, 2011 - Meeting/Conference Proceedings Salzburg Global Seminar Session 565—Better Health Care: How Do We Learn About Improvement? Citation Text: Salzburg Global Seminar Session 565—Better Health Care: How Do We Learn About Improvement? Massoud MR, Kimble LE, Goldmann D, eds. Int J Qual Health Ca…

Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). | PSNet

psnet.ahrq.gov/issue/medication-safety-advancing-development-improvement

January 08, 2020 - Grant Announcement Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). Citation Text: Medication Safety: Advancing the Development of Improvement Strategies and Tools (R18). Rockville, MD: Agency for Healthcare Research and Quality; Septembe…

Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. | PSNet

psnet.ahrq.gov/issue/advancing-diagnostic-excellence-older-adults-proceedings-workshop-brief

April 20, 2022 - Book/Report Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. Citation Text: Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief. National Academies of Sciences, Engineering, and Medicine. Washington, DC: The…

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. | PSNet

psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture

May 02, 2018 - Newspaper/Magazine Article Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. Citation Text: Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. ISMP Medication Safety Alert! …

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. | PSNet

psnet.ahrq.gov/issue/three-new-best-practices-2022-2023-targeted-medication-safety-best-practices-hospitals

March 15, 2022 - Newspaper/Magazine Article Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. Citation Text: Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. ISMP Medication Safety Alert! Acute care edition…

Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. | PSNet

psnet.ahrq.gov/issue/handoff-checklists-improve-reliability-patient-handoffs-operating-room-and-postanesthesia

December 29, 2014 - Study Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Citation Text: Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaes…

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation. | PSNet

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January 04, 2017 - Book/Report Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation. Citation Text: Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation. Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887. C…

Do no unconscious harm. | PSNet

psnet.ahrq.gov/issue/do-no-unconscious-harm

October 14, 2020 - Newspaper/Magazine Article Do no unconscious harm. Citation Text: Ortega RP. Do no unconscious harm. Science. 2023;379(6635):870-873. doi:10.1126/science.adh3698. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

Suicide in the medical setting. | PSNet

psnet.ahrq.gov/issue/suicide-medical-setting

April 24, 2018 - Review Suicide in the medical setting. Citation Text: Ballard ED, Pao M, Henderson D, et al. Suicide in the medical setting. Jt Comm J Qual Patient Saf. 2008;34(8):474-481. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

Medication room madness: calming the chaos. | PSNet

psnet.ahrq.gov/issue/medication-room-madness-calming-chaos

January 22, 2016 - Commentary Medication room madness: calming the chaos. Citation Text: Conrad C, Fields W, McNamara T, et al. Medication room madness: calming the chaos. J Nurs Care Qual. 2010;25(2):137-144. doi:10.1097/NCQ.0b013e3181c3695d. Copy Citation Format: DOI Google Scholar PubMed B…

The Canadian Quality and Patient Safety Framework for Health and Social Services. | PSNet

psnet.ahrq.gov/issue/canadian-quality-and-patient-safety-framework-health-and-social-services

December 09, 2020 - Multi-use Website The Canadian Quality and Patient Safety Framework for Health and Social Services. Citation Text: The Canadian Quality and Patient Safety Framework for Health and Social Services. Canadian Patient Safety Institute and Health Standards Organization. Copy Citation …

Talking with Patients and Families about Medical Error: A Guide for Education and Practice. | PSNet

psnet.ahrq.gov/issue/talking-patients-and-families-about-medical-error-guide-education-and-practice

July 24, 2019 - Book/Report Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Citation Text: Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins…

Education is “predictably disappointing” and should never be relied upon alone to improve safety. | PSNet

psnet.ahrq.gov/issue/education-predictably-disappointing-and-should-never-be-relied-upon-alone-improve-safety

June 15, 2022 - Newspaper/Magazine Article Education is “predictably disappointing” and should never be relied upon alone to improve safety. Citation Text: Education is “predictably disappointing” and should never be relied upon alone to improve safety. ISMP Medication Safety Alert! Acute care edition. …

Systemic error in radiology. | PSNet

psnet.ahrq.gov/issue/systemic-error-radiology

August 01, 2018 - Commentary Systemic error in radiology. Citation Text: Waite S, Scott JM, Legasto A, et al. Systemic Error in Radiology. AJR Am J Roentgenol. 2017;209(3):629-639. doi:10.2214/AJR.16.17719. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML E…

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