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psnet.ahrq.gov/issue/performing-inadvertent-procedure
October 16, 2019 - Commentary
Performing an inadvertent procedure.
Citation Text:
Gupta A, Jain S, Croft C. Performing an Inadvertent Procedure. JAMA. 2019;321(5):504-505. doi:10.1001/jama.2018.21438.
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psnet.ahrq.gov/issue/guiding-principles-achieve-continuity-medication-management
October 14, 2020 - Book/Report
Guiding Principles to Achieve Continuity in Medication Management.
Citation Text:
Guiding Principles to Achieve Continuity in Medication Management. Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1-76007-471-5.
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psnet.ahrq.gov/issue/patients-view-2004-isqsh-national-survey
July 20, 2022 - Book/Report
The Patients' View: 2004 ISQSH National Survey.
Citation Text:
The Patients' View: 2004 ISQSH National Survey. Dublin: Irish Society for Quality and Safety in Healthcare; 2004.
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psnet.ahrq.gov/issue/risk-models-improve-safety-dispensing-high-alert-medications-community-pharmacies
December 02, 2020 - Study
Risk models to improve safety of dispensing high-alert medications in community pharmacies.
Citation Text:
Cohen MR, Smetzer JL, Westphal JE, et al. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003). 2012;52(5):584-6…
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psnet.ahrq.gov/issue/intravenous-iv-push-medications-bridging-gap-between-education-and-clinical-practice
November 17, 2021 - Newspaper/Magazine Article
Intravenous (IV) push medications – bridging the gap between education and clinical practice.
Citation Text:
Intravenous (IV) push medications – bridging the gap between education and clinical practice. ISMP Medication Safety Alert! Acute Care. November 2, …
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psnet.ahrq.gov/issue/costly-issues-uncommunicative-or
July 29, 2020 - Newspaper/Magazine Article
Costly issues of an uncommunicative OR.
Citation Text:
Neil R. Costly issues of an uncommunicative OR. Materials management in health care. 2006;15(3):30-3.
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psnet.ahrq.gov/issue/ashp-statement-pharmacists-role-medication-reconciliation
June 30, 2021 - Commentary
ASHP statement on the pharmacist's role in medication reconciliation.
Citation Text:
ASHP Statement on the Pharmacist’s Role in Medication Reconciliation. Am J Health Syst Pharm. 2013;70(5):453-456. doi:10.2146/sp120009.
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psnet.ahrq.gov/issue/certified-pharmacy-technicians-views-their-medication-preparation-errors-and-educational
June 03, 2015 - Study
Certified pharmacy technicians' views on their medication preparation errors and educational needs.
Citation Text:
Desselle SP. Certified pharmacy technicians' views on their medication preparation errors and educational needs. Am J Health Syst Pharm. 2005;62(19):1992-7.
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psnet.ahrq.gov/issue/shot-annual-report-2019
July 10, 2019 - Book/Report
SHOT Annual Report.
Citation Text:
SHOT Annual Report. S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2023. ISBN: 9781999596859.
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psnet.ahrq.gov/issue/they-were-his-best-shot-and-they-failed-help-why-did-ems-workers-neglect-tyre-nichols
July 19, 2023 - Newspaper/Magazine Article
'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols?
Citation Text:
'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols? Renault M. STAT. February 6, 2023.
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psnet.ahrq.gov/issue/nursing-handovers-resilient-points-care-linking-handover-strategies-treatment-errors-patient
August 30, 2017 - Study
Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift.
Citation Text:
Drach-Zahavy A, Hadid N. Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the p…
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psnet.ahrq.gov/issue/making-checklists-work-south-carolinas-statewide-experiment
April 01, 2015 - Newspaper/Magazine Article
Making checklists work: South Carolina's statewide experiment.
Citation Text:
Rice S. MAKING CHECKLISTS WORK. Modern healthcare. 2016;46(4):14-6.
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psnet.ahrq.gov/issue/critical-laboratory-value-notification-failure-mode-effects-and-criticality-analysis
June 27, 2018 - Commentary
Critical laboratory value notification: a failure mode effects and criticality analysis.
Citation Text:
Saxena S, Kempf R, Wilcox S, et al. Critical laboratory value notification: a failure mode effects and criticality analysis. Jt Comm J Qual Patient Saf. 2005;31(9):495-506…
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psnet.ahrq.gov/issue/instrument-count-sheets-and-set-reviews-patient-safety-tools
February 28, 2011 - Commentary
Instrument count sheets and set reviews as patient safety tools.
Citation Text:
Spear J. Instrument Count Sheets and Set Reviews as Patient Safety Tools. AORN J. 2016;104(6):588-592. doi:10.1016/j.aorn.2016.10.007.
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psnet.ahrq.gov/issue/fda-end-program-hid-millions-reports-faulty-medical-devices
May 17, 2017 - Newspaper/Magazine Article
FDA to end program that hid millions of reports on faulty medical devices.
Citation Text:
FDA to end program that hid millions of reports on faulty medical devices. Jewett C. Kaiser Health News. May 3, 2019.
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psnet.ahrq.gov/issue/internal-bleeding-truth-behind-americas-terrifying-epidemic-medical-mistakes-updated-edition
March 27, 2005 - Book/Report
Classic
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.
Citation Text:
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition. Wachter R, Shojan…
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psnet.ahrq.gov/issue/incidence-adverse-events-indian-health-service-hospitals
May 20, 2020 - Book/Report
Incidence of Adverse Events in Indian Health Service Hospitals.
Citation Text:
Incidence of Adverse Events in Indian Health Service Hospitals. Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.
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psnet.ahrq.gov/issue/how-nursing-homes-worst-offenses-are-hidden-public
September 22, 2021 - Newspaper/Magazine Article
How nursing homes’ worst offenses are hidden from the public.
Citation Text:
How nursing homes’ worst offenses are hidden from the public. Gebeloff R, Thomas K, Silver-Greenberg J. New York Times. December 9, 2021.
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psnet.ahrq.gov/issue/assessment-national-patient-safety-initiative-context-and-baseline-evaluation-report-1
May 21, 2014 - Book/Report
Assessment of the National Patient Safety Initiative: Context and Baseline Evaluation Report 1.
Citation Text:
Assessment of the National Patient Safety Initiative: Context and Baseline Evaluation Report 1. Santa Monica, CA: RAND Corporation; 2005. ISBN 0833037870.
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psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-final-report-evaluation-report-iv
May 21, 2014 - Book/Report
Assessment of the AHRQ Patient Safety Initiative: Final Report Evaluation Report IV.
Citation Text:
Assessment of the AHRQ Patient Safety Initiative: Final Report Evaluation Report IV. Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2008. ISBN: 9…