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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - So there is a handoff occurring at discharge, and
I often think just like you would communicate and
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psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - Handoffs are occurring at multiple levels in the system at the same
time.
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psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
September 29, 2021 - Newspaper/Magazine Article
RaDonda Vaught says some system practices contributed to fatal mistake.
Citation Text:
RaDonda Vaught says some system practices contributed to fatal mistake. Clark C. MedPage Today. March 14, 2024.
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psnet.ahrq.gov/issue/2012-ismp-international-medication-safety-self-assessment-oncology
January 26, 2023 - Press Release/Announcement
2012 ISMP International Medication Safety Self Assessment for Oncology.
Citation Text:
2012 ISMP International Medication Safety Self Assessment for Oncology. Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada.
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psnet.ahrq.gov/issue/funding-announcement-projects-targeting-reduction-healthcare-associated-infections
August 01, 2012 - Grant Announcement
Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections.
Citation Text:
Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections. Rockville, MD: Agency for Healthcare Research and Quality; July …
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psnet.ahrq.gov/issue/surgical-fires-decreasing-incidence-relies-continued-prevention-efforts
April 03, 2019 - Newspaper/Magazine Article
Surgical fires: decreasing incidence relies on continued prevention efforts.
Citation Text:
Surgical fires: decreasing incidence relies on continued prevention efforts. Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June…
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psnet.ahrq.gov/issue/report-safe-use-pick-lists-ambulatory-care-settings
June 29, 2016 - Government Resource
Report on the Safe Use of Pick Lists in Ambulatory Care Settings.
Citation Text:
Report on the Safe Use of Pick Lists in Ambulatory Care Settings. Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
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psnet.ahrq.gov/issue/new-mother-number-14
August 18, 2021 - Commentary
New mother number 14.
Citation Text:
New mother number 14. Sangarlangkarn A. Healthc (Amst). 2019;7:31-32.
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psnet.ahrq.gov/issue/healthgrades-quality-study-fourth-annual-patient-safety-american-hospitals-study
January 04, 2017 - Book/Report
HealthGrades Quality Study: Fourth Annual Patient Safety in American Hospitals Study.
Citation Text:
HealthGrades Quality Study: Fourth Annual Patient Safety in American Hospitals Study. Denver, CO; Health Grades Inc; 2007.
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psnet.ahrq.gov/issue/missed-injuries-trauma-patients-literature-review
April 01, 2009 - Review
Missed injuries in trauma patients: a literature review.
Citation Text:
Pfeifer R, Pape H-C. Missed injuries in trauma patients: A literature review. Patient Saf Surg. 2008;2:20. doi:10.1186/1754-9493-2-20.
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DOI Google Scholar PubMed BibTeX End…
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psnet.ahrq.gov/issue/defending-never-event
February 14, 2017 - Commentary
Defending a "never event."
Citation Text:
Shepperd JR. Defending a "Never Event". J Healthc Risk Manag. 2017;37(1):17-22. doi:10.1002/jhrm.21277.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/adoption-technology-improve-medication-safety-perspectives-pharmacy-directors
February 15, 2011 - Study
Adoption of technology to improve medication safety: perspectives of pharmacy directors.
Citation Text:
Bussard BE, McAlearney AS, Pedersen CA, et al. Adoption of Technology to Improve Medication Safety. J Patient Saf. 2008;2(4). doi:10.1097/01.jps.0000236914.48955.99.
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psnet.ahrq.gov/issue/barriers-adverse-event-and-error-reporting-anesthesia
April 19, 2017 - Study
Barriers to adverse event and error reporting in anesthesia.
Citation Text:
Heard GC, Sanderson PM, Thomas RD. Barriers to Adverse Event and Error Reporting in Anesthesia. Anesthesia & Analgesia. 2011;114(3). doi:10.1213/ane.0b013e31822649e8.
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Format:
D…
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psnet.ahrq.gov/issue/fda-public-health-notification-unretrieved-device-fragments
June 02, 2021 - Press Release/Announcement
FDA public health notification: unretrieved device fragments.
Citation Text:
FDA public health notification: unretrieved device fragments. Silver Spring MD, Center for Devices and Radiological Health, US Food and Drug Administration; January 15, 2008.
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psnet.ahrq.gov/issue/patient-safety-2030
April 13, 2016 - Book/Report
Patient Safety 2030.
Citation Text:
Patient Safety 2030. Yu A, Flott K, Chainani N, Fontana G, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
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psnet.ahrq.gov/issue/establishing-culture-patient-safety-role-education
August 23, 2017 - Commentary
Establishing a culture for patient safety - the role of education.
Citation Text:
Milligan FJ. Establishing a culture for patient safety - the role of education. Nurse Educ Today. 2007;27(2):95-102.
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psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients
April 17, 2024 - Newspaper/Magazine Article
Total systems safety supports practitioners in partnering with families to protect patients.
Citation Text:
Total systems safety supports practitioners in partnering with families to protect patients. ISMP Medication Safety Alert! Acute Care. 2024;29(13):1-4.
…
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psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
March 23, 2012 - Book/Report
Classic
Serious Reportable Events in Healthcare—2011 Update.
Citation Text:
Serious Reportable Events in Healthcare—2011 Update. Washington DC: National Quality Forum; December 2011.
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psnet.ahrq.gov/issue/drug-shortages-national-survey-reveals-high-level-frustration-low-level-safety
April 05, 2023 - Newspaper/Magazine Article
Drug shortages: national survey reveals high level of frustration, low level of safety.
Citation Text:
Drug shortages: national survey reveals high level of frustration, low level of safety. ISMP Medication Safety Alert! Acute Care Edition. September 23, 2010:1…
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psnet.ahrq.gov/issue/errors-diagnosis-spinal-epidural-abscesses-era-electronic-health-records
April 24, 2018 - Study
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
Citation Text:
Bhise V, Meyer AND, Singh H, et al. Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records. Am J Med. 2017;130(8). doi:10.1016/j.amjmed.2017.03…