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psnet.ahrq.gov/node/41216/psn-pdf
June 12, 2018 - Smart pump custom concentrations without hard "low
concentration" alerts.
June 12, 2018
ISMP Medication Safety Alert! Acute care edition. February 23, 2012;17:1,3-4.
https://psnet.ahrq.gov/issue/smart-pump-custom-concentrations-without-hard-low-concentration-alerts
This newsletter piece reviews smart infusion pump…
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psnet.ahrq.gov/periodic-issue/periodic-issue-396
June 28, 2023 - Study
Evaluation of detected medication errors within the operating room at an … review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication … error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular
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psnet.ahrq.gov/issue/persistent-problem-diagnostic-error
July 17, 2013 - Newspaper/Magazine Article
The persistent problem of diagnostic error.
Citation Text:
The persistent problem of diagnostic error. Lundberg GD. Medscape. December 1, 2015.
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psnet.ahrq.gov/periodic-issue/periodic-issue-315
October 27, 2021 - October 27, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/issue/getting-it-right-patient-safety-specimen-collection-process-improvement-operating-room
July 16, 2013 - July 15, 2020
Economic analysis of the prevalence and clinical and economic burden of medication … error in England.
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psnet.ahrq.gov/issue/effect-staff-nurses-shift-length-and-fatigue-patient-safety-and-nurses-health-national
July 06, 2011 - Nurses' work-related fatigue has the potential to contribute to medication errors and missed nursing
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psnet.ahrq.gov/node/35363/psn-pdf
April 03, 2012 - The MacArthur Fellows Program: Michael Cohen.
April 3, 2012
The John D. and Catherine T. MacArthur Foundation.
https://psnet.ahrq.gov/issue/macarthur-fellows-program-michael-cohen
Michael Cohen, President of the Institute for Safe Medication Practices, has focused his career on
preventing medical errors with innov…
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psnet.ahrq.gov/issue/when-mistakes-multiply-how-inadequate-responses-medical-mishaps-erode-trust-american-medicine
April 24, 2019 - September 23, 2020
Economic analysis of the prevalence and clinical and economic burden of medication … error in England.
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psnet.ahrq.gov/issue/accuracy-interpretation-preparticipation-screening-electrocardiograms
May 18, 2022 - February 25, 2015
ISMP medication error report analysis.
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psnet.ahrq.gov/issue/experimental-study-medical-error-explanations-do-apology-empathy-corrective-action-and
October 07, 2020 - June 30, 2011
Field test results of a new ambulatory care Medication Error and Adverse
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psnet.ahrq.gov/issue/call-excellence
May 20, 2009 - Commentary
A call to excellence.
Citation Text:
Clancy CM, Scully T. A call to excellence. Health Aff (Millwood). 2003;22(2):113-5.
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psnet.ahrq.gov/issue/interruptions-healthcare-theoretical-views
September 24, 2016 - Review
Interruptions in healthcare: theoretical views.
Citation Text:
Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform. 2009;78(5):293-307. doi:10.1016/j.ijmedinf.2008.10.001.
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psnet.ahrq.gov/issue/health-informatics-healthcare-quality-and-safety-and-healthcare-simulation-new-triad-advance
April 28, 2021 - Special or Theme Issue
Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations
Citation Text:
Health Informatics, Healthcare Quality and Safety, and Healthcare Simulation: the New Triad to Advance Healthcare Operations …
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psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
December 20, 2017 - Book/Report
SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience.
Citation Text:
SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
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psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion
May 03, 2023 - Newspaper/Magazine Article
Smart infusion pump investigations after an unexplained over-infusion.
Citation Text:
Smart infusion pump investigations after an unexplained over-infusion. ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.
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psnet.ahrq.gov/issue/economics-patient-safety-strengthening-value-based-approach-reducing-patient-harm-national
May 02, 2018 - Book/Report
The Economics of Patient Safety: Strengthening a Value-based Approach to Reducing Patient Harm at National Level.
Citation Text:
The Economics of Patient Safety: Strengthening a Value-based Approach to Reducing Patient Harm at National Level. Slawomirski L, Auraaen A, Klazing…
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psnet.ahrq.gov/issue/introducing-new-technology-safely
April 01, 2010 - Commentary
Introducing new technology safely.
Citation Text:
Mytton OT, Velazquez A, Banken R, et al. Introducing new technology safely. Qual Saf Health Care. 2010;19 Suppl 2:i9-14. doi:10.1136/qshc.2009.038554.
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psnet.ahrq.gov/issue/diagnostic-safety-toolkit
December 05, 2024 - Toolkit
Diagnostic Safety Toolkit.
Citation Text:
Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital Association. May 2020.
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psnet.ahrq.gov/issue/redesigning-morbidity-and-mortality-program-university-affiliated-pediatric-anesthesia
March 27, 2024 - Commentary
Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.
Citation Text:
McDonnell C, Laxer RM, Roy L. Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/health-literacy-and-mortality-among-elderly-persons
April 24, 2018 - Study
Health literacy and mortality among elderly persons.
Citation Text:
Baker DW, Wolf MS, Feinglass J, et al. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1503-9.
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