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psnet.ahrq.gov/node/840169/psn-pdf
November 16, 2022 - ISMP survey on tall man (mixed case) lettering to reduce
drug name confusion.
November 16, 2022
Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
Mixed case letters are one suggested strategy to reduce look-alike medication na…
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psnet.ahrq.gov/node/60589/psn-pdf
June 23, 2020 - Medication Safety During the COVID-19 Pandemic: What
Have We Learned in the United States.
June 23, 2020
Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information.
June 23, 2020.
https://psnet.ahrq.gov/issue/medication-safety-during-covid-19-pandemic-what-have-we-lear…
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psnet.ahrq.gov/node/36069/psn-pdf
May 11, 2014 - Health literacy, medication errors, and health outcomes:
is there a relationship?
May 11, 2014
Warner A, Menachemi N, Brooks RG. Health Literacy, Medication Errors, and Health Outcomes: Is There a
Relationship? Hosp Pharm. 2010;41(6):542-551. doi:10.1310/hpj4106-538.
https://psnet.ahrq.gov/issue/health-literacy-me…
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psnet.ahrq.gov/node/847733/psn-pdf
March 16, 2025 - ISMP Targeted Medication Safety Best Practices for
Community Pharmacy.
March 16, 2025
Institute for Safe Medication Practices: March 2025.
https://psnet.ahrq.gov/issue/ismp-targeted-medication-safety-best-practices-community-pharmacy
Community pharmacies are common providers of medication delivery that harbor proc…
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psnet.ahrq.gov/node/47615/psn-pdf
January 30, 2019 - A Crisis in Health Care: A Call to Action on Physician
Burnout.
January 30, 2019
Jha AK, Iliff AR, Chaoui AA, et al. Waltham, MA: Massachusetts Medical Society, Massachusetts Health
and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute;
2019.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/39960/psn-pdf
September 19, 2016 - Respectful Management of Serious Clinical Adverse
Events. Second Edition.
September 19, 2016
Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement;
2011.
https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
This white paper e…
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psnet.ahrq.gov/node/43579/psn-pdf
October 08, 2014 - Implications of Health Literacy for Public Health:
Workshop Summary.
October 8, 2014
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/47738/psn-pdf
February 06, 2019 - ISMP Guidelines for Safe Electronic Communication of
Medication Information.
February 6, 2019
Horsham, PA: Institute for Safe Medication Practices; January 2019.
https://psnet.ahrq.gov/issue/ismp-guidelines-safe-electronic-communication-medication-information
Inaccurate or incomplete data in electronic health reco…
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psnet.ahrq.gov/node/47456/psn-pdf
April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push
Medication Practices.
April 30, 2019
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
Standardized practices have not been uniformly adopted to support safe IV medicati…
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psnet.ahrq.gov/node/74194/psn-pdf
December 15, 2021 - Age-related COVID-19 vaccine mix-ups.
December 15, 2021
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. December 6, 2021.
https://psnet.ahrq.gov/issue/age-related-covid-19-vaccine-mix-ups
Vaccine missteps are known to …
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/836969/psn-pdf
April 20, 2022 - Criminalization of human error and a guilty verdict: a
travesty of justice that threatens patient safety.
April 20, 2022
ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.
https://psnet.ahrq.gov/issue/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-
patient-safety…
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psnet.ahrq.gov/node/72829/psn-pdf
March 10, 2021 - Safe Practices to Reduce CPOE Alert Fatigue through
Monitoring, Analysis, and Optimization.
March 10, 2021
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.
https://psnet.ahrq.gov/issue/safe-practices-reduce-cpoe-alert-fatigue-through-monitoring-analysis-and-
optimization
Alert…
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psnet.ahrq.gov/node/45668/psn-pdf
September 29, 2017 - Development of a high-value care culture survey: a
modified Delphi process and psychometric evaluation.
September 29, 2017
Gupta R, Moriates C, Harrison JD, et al. Development of a high-value care culture survey: a modified
Delphi process and psychometric evaluation. BMJ Qual Saf. 2017;26(6):475-483. doi:10.1136/bm…
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psnet.ahrq.gov/node/33562/psn-pdf
September 15, 2024 - Rapid Response Systems
September 15, 2024
Rapid Response Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/rapid-response-systems
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.…
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - many are
referred from outside facilities such as other EDs, nursing homes, or local clinics (at our institution
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psnet.ahrq.gov/node/836892/psn-pdf
April 07, 2022 - recommend that sites do the following:
Ensure adoption and support of the initiative by the entire institution
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Patient safety is an important issue at every health care institution in our country.
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - experience and
preference, guided by how tracheostomy supplies are managed and made available in an institution
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - and the healthcare system would have been better served by a palliative care consult
and possible institution