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psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy
June 07, 2017 - Book/Report
Root Cause Analysis Workbook for Community/Ambulatory Pharmacy.
Citation Text:
Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. Horsham, PA: Institute for Safe Medication Practices; 2013.
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psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion-pumps
June 07, 2017 - Organizational Policy/Guidelines
ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps.
Citation Text:
ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. Horsham, PA: Institute for Safe Medication Practices; 2020.
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psnet.ahrq.gov/issue/guidance-safe-use-automated-dispensing-cabinets
February 06, 2019 - Organizational Policy/Guidelines
Guidance for the Safe Use of Automated Dispensing Cabinets.
Citation Text:
Guidance for the Safe Use of Automated Dispensing Cabinets. Horsham, PA: Institute for Safe Medication Practices; 2019.
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - modes ( n =32) were not analyzed by any of the 3 facilities in the proactive risk assessments but were listed
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psnet.ahrq.gov/issue/medication-reconciliation-geriatric-unit-impact-maintenance-post-hospitalization
December 01, 2021 - Study
Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescriptions.
Citation Text:
Montaleytang M, Correard F, Spiteri C, et al. Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescrip…
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psnet.ahrq.gov/issue/observational-study-drug-formulation-manipulation-pediatric-versus-adult-inpatients
June 08, 2022 - Study
Observational study of drug formulation manipulation in pediatric versus adult inpatients.
Citation Text:
Spishock S, Meyers R, Robinson CA, et al. Observational Study of Drug Formulation Manipulation in Pediatric Versus Adult Inpatients. J Patient Saf. 2021;17(1):e10-e14. doi:10.1…
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psnet.ahrq.gov/issue/addressing-racial-and-ethnic-bias-pulse-oximeters-wicked-problem
April 18, 2019 - Commentary
Addressing racial and ethnic bias in pulse oximeters—a wicked problem.
Citation Text:
Shachar C, Drabo EF, Iwashyna TJ, et al. Addressing racial and ethnic bias in pulse oximeters—a wicked problem. JAMA. 2025;333(7):563-564. doi:10.1001/jama.2024.25443.
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psnet.ahrq.gov/issue/artificial-intelligence-related-safety-issues-associated-fda-medical-device-reports
May 29, 2024 - Study
Artificial intelligence related safety issues associated with FDA medical device reports.
Citation Text:
Handley JL, Krevat SA, Fong A, et al. Artificial intelligence related safety issues associated with FDA medical device reports. NPJ Digit Med. 2024;7(1):351. doi:10.1038/s41746-…
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/33867/psn-pdf
October 01, 2018 - If you tried to prescribe
something else, "We don't have this listed for diabetes.
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psnet.ahrq.gov/issue/ismp-medication-safety-self-assessment-high-alert-medications
June 07, 2017 - Measurement Tool/Indicator
ISMP Medication Safety Self Assessment for High-Alert Medications.
Citation Text:
ISMP Medication Safety Self Assessment for High-Alert Medications. Horsham, PA: Institute for Safe Medication Practices; 2017.
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psnet.ahrq.gov/issue/ny-medicaid-ups-ante-refusing-pay-14-never-events-nations-biggest-medicaid-program-could
December 16, 2009 - Newspaper/Magazine Article
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
Citation Text:
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid p…
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psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-leading-drug
June 10, 2018 - Newspaper/Magazine Article
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.
Citation Text:
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety…
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - Newsletter/Journal
ISMP Long-Term Care Advise-ERR.
Citation Text:
ISMP Long-Term Care Advise-ERR. Horsham, PA; Institute for Safe Medication Practices.
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psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
June 13, 2018 - Toolkit
ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.
Citation Text:
ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2018.
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psnet.ahrq.gov/issue/guidelines-adult-iv-push-medications
April 01, 2015 - Book/Report
Guidelines for Adult IV Push Medications.
Citation Text:
Guidelines for Adult IV Push Medications. Horsham, PA: The Institute for Safe Medication Practices; July 2015.
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psnet.ahrq.gov/issue/error-reporting-organizations
May 24, 2006 - Commentary
Error reporting in organizations.
Citation Text:
Error reporting in organizations. Zhao B; Olivera F. Acad Manag Rev. 2006;31(4):1012-1030.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry
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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - Three illustrative cases from the
Food and Drug Administration’s Medical Device Reporting system are listed
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psnet.ahrq.gov/node/38933/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-38
This monthly selection of error reports discusses incidents involving insulin preparation, automated
medication cabinet stocking, and medication list filing.
https://psnet.ahrq.gov/…