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psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-codes
November 02, 2022 - Newspaper/Magazine Article
Survey results from pharmacists provide support to enhance the organizational response to codes.
Citation Text:
Survey results from pharmacists provide support to enhance the organizational response to codes. ISMP Medication Safety Alert! Acute care edition. Oc…
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psnet.ahrq.gov/issue/condition-concern-innovative-response-system-enhancing-hospitalized-patient-care-and-safety
April 24, 2018 - Commentary
Condition concern: an innovative response system for enhancing hospitalized patient care and safety.
Citation Text:
Baird SK, Turbin LB. Condition concern: an innovative response system for enhancing hospitalized patient care and safety. J Nurs Care Qual. 2011;26(3):199-207. d…
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psnet.ahrq.gov/issue/acog-committee-opinion-680-use-and-development-checklists-obstetrics-and-gynecology
December 14, 2016 - Commentary
ACOG Committee opinion #680: the use and development of checklists in obstetrics and gynecology.
Citation Text:
ACOG Committee opinion #680: the use and development of checklists in obstetrics and gynecology. American College of Obstetricians and Gynecologists’ Committee on Pa…
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psnet.ahrq.gov/issue/getting-it-right-when-things-go-wrong
October 20, 2014 - Commentary
Getting it right when things go wrong.
Citation Text:
Pettker CM, Funai EF. Getting it right when things go wrong. JAMA. 2010;303(10):977-8. doi:10.1001/jama.2010.256.
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psnet.ahrq.gov/issue/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility
July 27, 2016 - Newspaper/Magazine Article
Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.
Citation Text:
Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6. …
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www.ahrq.gov/news/newsroom/case-studies/202104.html
October 01, 2021 - CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System
Search All Impact Case Studies
October 2021
CommonSpirit Health, one of the Nation's largest health systems, serving 21 States, is expanding its use of AHRQ's Communication and Optimal Resolution (CANDOR) toolkit across its entire netw…
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psnet.ahrq.gov/issue/public-meeting-improving-patient-safety-enhancing-container-labeling-parenteral-infusion-drug
December 16, 2020 - Government Resource
Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products.
Citation Text:
Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products. Fed Reg. Nov. 28,…
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psnet.ahrq.gov/issue/medical-error-what-do-we-know-what-do-we-do
May 06, 2016 - Book/Report
Classic
Medical Error: What Do We Know? What Do We Do?
Citation Text:
Medical Error: What Do We Know? What Do We Do? Rosenthal MM; Sutcliffe KM, eds. San Francisco, CA: Jossey-Bass; 2002.
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psnet.ahrq.gov/issue/2019-update-medical-overuse-review
May 05, 2021 - Review
Emerging Classic
2019 update on medical overuse: a review.
Citation Text:
Morgan DJ, Dhruva SS, Coon ER, et al. 2019 update on medical overuse: a review. JAMA Intern Med. 2019;179(11):1568. doi:10.1001/jamainternmed.2019.3842.
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psnet.ahrq.gov/issue/two-effective-initiatives-c-suite-leaders-improve-medication-safety-and-reliability-outcomes
March 14, 2023 - Newspaper/Magazine Article
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.
Citation Text:
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. ISMP Medication Safety Alert! …
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psnet.ahrq.gov/issue/learning-and-sharing-safety-lessons-improve-patient-care
August 07, 2019 - Commentary
Learning and sharing safety lessons to improve patient care.
Citation Text:
Woodward S. Learning and sharing safety lessons to improve patient care. Nursing Standard. 2016;20(18). doi:10.7748/ns.20.18.49.s52.
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psnet.ahrq.gov/issue/school-nursing-quality-and-safety-officer-nursing-students-use-safety-reporting-tools-and
October 19, 2022 - Study
From the school of nursing quality and safety officer: nursing students' use of safety reporting tools and their perception of safety issues in clinical settings.
Citation Text:
Cooper E. From the school of nursing quality and safety officer: nursing students' use of safety report…
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psnet.ahrq.gov/issue/role-apology-laws-medical-malpractice
July 29, 2020 - Commentary
The role of apology laws in medical malpractice.
Citation Text:
The role of apology laws in medical malpractice. Ross NE, Newman WJ. J Am Acad Psychiatry Law. 2021;49(3):406-414.
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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! …
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psnet.ahrq.gov/issue/diagnostic-error-and-clinical-reasoning
February 06, 2013 - Review
Diagnostic error and clinical reasoning.
Citation Text:
Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44(1):94-100. doi:10.1111/j.1365-2923.2009.03507.x.
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psnet.ahrq.gov/issue/nurses-guilty-verdict-dosing-mistake-could-cost-lives
April 27, 2022 - Newspaper/Magazine Article
Nurses: Guilty verdict for dosing mistake could cost lives.
Citation Text:
Nurses: Guilty verdict for dosing mistake could cost lives. Loller T. Associated Press. March 30, 2022.
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psnet.ahrq.gov/issue/remembering-learn-overlooked-role-remembrance-safety-improvement
February 28, 2024 - Commentary
Remembering to learn: the overlooked role of remembrance in safety improvement.
Citation Text:
Macrae C. Remembering to learn: the overlooked role of remembrance in safety improvement. BMJ Qual Saf. 2017;26(8):678-682. doi:10.1136/bmjqs-2016-005547.
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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.
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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. …
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psnet.ahrq.gov/issue/eighth-annual-national-patient-safety-foundation-congress-conference-proceedings
November 29, 2017 - Meeting/Conference Proceedings
Eighth Annual National Patient Safety Foundation Congress: Conference Proceedings.
Citation Text:
Eighth Annual National Patient Safety Foundation Congress: Conference Proceedings. Stepnick L, Edgman-Levitan S, Kaplan GS et al. J Patient Saf. 2006;2(2):…