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psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution
November 03, 2015 - Study
Risk of medication errors at hospital discharge and barriers to problem resolution.
Citation Text:
Risk of medication errors at hospital discharge and barriers to problem resolution. Enguidanos SM; Brumley RD.
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psnet.ahrq.gov/issue/understanding-and-managing-iv-container-overfill
June 10, 2018 - Newspaper/Magazine Article
Understanding and managing IV container overfill.
Citation Text:
Understanding and managing IV container overfill. ISMP Medication Safety Alert! Acute care edition. November 14, 2013;18:1-4.
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psnet.ahrq.gov/issue/fentanyl-patch-fatalities-linked-bystander-apathy-we-all-have-role-prevention
May 07, 2014 - Newspaper/Magazine Article
FentaNYL patch fatalities linked to "bystander apathy." We ALL have a role in prevention!
Citation Text:
FentaNYL patch fatalities linked to "bystander apathy." We ALL have a role in prevention! ISMP Medication Safety Alert! Acute care edition! August 8, 2013…
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.
Citation Text:
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Mental Health Care (Psychiatry and Clinical Psychology) Go to this topic
Neurology
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psnet.ahrq.gov/issue/pharmacy-led-medication-reconciliation-best-practice
September 30, 2020 - Newspaper/Magazine Article
Pharmacy-led medication reconciliation is best practice.
Citation Text:
Pharmacy-led medication reconciliation is best practice. Tanski MC. Pharmacy Times Health Systems edition. September 2023;12(5):34-35.
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psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better
February 13, 2019 - Newspaper/Magazine Article
With oral chemotherapy, we simply must do better!
Citation Text:
With oral chemotherapy, we simply must do better! ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
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psnet.ahrq.gov/issue/doctors-orders-killed-cancer-patient-dana-farber-admits-drug-overdose-caused-death-globe
March 10, 2021 - Newspaper/Magazine Article
Classic
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Citation Text:
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused deat…
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psnet.ahrq.gov/issue/report-focuses-risk-patients-ed-errors
June 26, 2019 - Newspaper/Magazine Article
Report focuses on risk to patients from ED errors.
Citation Text:
Report focuses on risk to patients from ED errors. Palmer J. Patient Saf Qual Healthcare. Sept/Oct 2019.
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psnet.ahrq.gov/web-mm/picking-cause-stroke
August 07, 2024 - Picking Up the Cause of the Stroke
Citation Text:
Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/issue/first-annual-review-data-submitted-ismp-national-vaccine-errors-reporting-program-verp
June 10, 2018 - Newspaper/Magazine Article
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).
Citation Text:
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). ISMP Medication Safety Alert! Acute Care Editi…
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psnet.ahrq.gov/issue/fda-advise-err-avoid-using-error-prone-abbreviation-tpa
April 29, 2015 - Newspaper/Magazine Article
FDA Advise-ERR: avoid using the error-prone abbreviation, TPA.
Citation Text:
FDA Advise-ERR: avoid using the error-prone abbreviation, TPA. ISMP Medication Safety Alert! Acute Care Edition. September 24, 2015;20:1,4-5.
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psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding-investigation-va-hospital
August 05, 2009 - Newspaper/Magazine Article
Suspicious insulin injections, nearly a dozen deaths: inside an unfolding investigation at a VA hospital in West Virginia.
Citation Text:
Suspicious insulin injections, nearly a dozen deaths: inside an unfolding investigation at a VA hospital in West Virginia.…
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psnet.ahrq.gov/issue/your-high-alert-medication-list-relatively-useless-without-associated-risk-reduction
May 07, 2014 - Newspaper/Magazine Article
Your high-alert medication list—relatively useless without associated risk-reduction strategies.
Citation Text:
Your high-alert medication list—relatively useless without associated risk-reduction strategies. ISMP Medication Safety Alert! Acute Care Edition. Ap…
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psnet.ahrq.gov/issue/ambulance-crew-chicago-got-lost-trying-find-hospital
May 28, 2014 - Newspaper/Magazine Article
Ambulance crew in Chicago got lost trying to find hospital.
Citation Text:
Ambulance crew in Chicago got lost trying to find hospital. News Services. Washington Post. October 25, 2007
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psnet.ahrq.gov/issue/survey-results-community-liaison-programs-decrease-hospital-readmissions
June 10, 2018 - Newspaper/Magazine Article
Survey results: community liaison programs to decrease hospital readmissions.
Citation Text:
Survey results: community liaison programs to decrease hospital readmissions. ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.
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psnet.ahrq.gov/issue/small-effort-big-payoffautomated-maximum-dose-alerts-hard-stops
June 10, 2018 - Newspaper/Magazine Article
Small effort, big payoff...automated maximum dose alerts with hard stops.
Citation Text:
Small effort, big payoff...automated maximum dose alerts with hard stops. ISMP Medication Safety Alert! Acute care edition! September 19, 2013;18:1-4.
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