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psnet.ahrq.gov/issue/high-cost-low-morale-clinical-laboratory-how-workplace-environment-impacts-patient-safety
March 06, 2005 - November 4, 2012
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/node/60653/psn-pdf
April 25, 2020 - Health Care Delivery and Pharmacists During the COVID-
19 Pandemic
June 29, 2020
Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
Medication…
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psnet.ahrq.gov/node/44093/psn-pdf
April 29, 2015 - South Carolina medication error bill is dangerously off
target.
April 29, 2015
ISMP Medication Safety Alert! Acute Care Edition. April 9, 2015;20:1,4.
https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target
This newsletter article reports on issues related to a legislation, drafted in …
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psnet.ahrq.gov/node/44420/psn-pdf
August 26, 2015 - Obstetric safety and quality.
August 26, 2015
Pettker CM, Grobman WA. Obstetric Safety and Quality. Obstet Gynecol. 2015;126(1):196-206.
doi:10.1097/AOG.0000000000000918.
https://psnet.ahrq.gov/issue/obstetric-safety-and-quality
Obstetric hospital admission has substantial potential for harm should something go wr…
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect adverse drug
events in the hospital setting.
March 10, 2011
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical
event monitor signals used to detect adverse …
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psnet.ahrq.gov/node/72807/psn-pdf
March 03, 2021 - Updated guidance needed for longstanding large volume
parenteral (LVP) labeling and packaging problems.
March 3, 2021
ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4.
https://psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-
and-packaging
…
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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psnet.ahrq.gov/node/42135/psn-pdf
April 22, 2013 - Interprofessional education in team communication:
working together to improve patient safety.
April 22, 2013
Brock DM, Abu-Rish E, Chiu C-R, et al. Interprofessional education in team communication: working
together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-23. doi:10.1136/bmjqs-2012-000952.
https:/…
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psnet.ahrq.gov/node/46143/psn-pdf
June 14, 2017 - Report of the Announced Inspection of Medication Safety
at the Midland Regional Hospital Tullamore, County
Offaly.
June 14, 2017
Dublin, Ireland: Health Information and Quality Authority; May 2017.
https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital-
tullamore-coun…
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psnet.ahrq.gov/node/45007/psn-pdf
March 30, 2016 - Medication errors involving healthcare students.
March 30, 2016
Hess L, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. March 2016;13:18-23.
https://psnet.ahrq.gov/issue/medication-errors-involving-healthcare-students
Using reports of medication errors submitted to the Pennsylvania Patient Safety Authority that …
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Temporarily holding medication orders safely in order to
prevent patient harm.
November 1, 2023
ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.
https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
Process disconnects can cause administr…
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psnet.ahrq.gov/node/74133/psn-pdf
January 01, 2022 - Predicting avoidable hospital events in Maryland.
December 1, 2021
Henderson M, Han F, Perman C, et al. Predicting avoidable hospital events in Maryland. Health Serv Res.
2022;57(1):192-199. doi:10.1111/1475-6773.13891.
https://psnet.ahrq.gov/issue/predicting-avoidable-hospital-events-maryland
With the goal of imp…
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psnet.ahrq.gov/node/47028/psn-pdf
May 02, 2018 - Medication errors 2018: the year in review.
May 2, 2018
Valentine D, Ingram V, Fobi BNN, Brahmbhatt V. Pharmacy Practice News. April 4, 2018.
https://psnet.ahrq.gov/issue/medication-errors-2018-year-review
Despite considerable effort, medication errors continue to occur and result in patient harm. Summari…
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psnet.ahrq.gov/node/60357/psn-pdf
May 20, 2020 - Preventing medication errors at small and rural hospitals.
May 20, 2020
McCook A. Preventing medication errors at small and rural hospitals. Pharmacy Practice News. May
6, 2020.
https://psnet.ahrq.gov/issue/preventing-medication-errors-small-and-rural-hospitals
Small and rural facilities experience similar m…
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psnet.ahrq.gov/node/47951/psn-pdf
April 24, 2019 - Safe medication management at ambulatory surgery
centers.
April 24, 2019
Ubaldi K. Safe Medication Management at Ambulatory Surgery Centers. AORN J. 2019;109(4):435-442.
doi:10.1002/aorn.12635.
https://psnet.ahrq.gov/issue/safe-medication-management-ambulatory-surgery-centers
Safe medication use can be challengin…
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psnet.ahrq.gov/node/37347/psn-pdf
March 28, 2012 - Recognition and management of potential drug-drug
interactions in patients on internal medicine wards.
March 28, 2012
Vonbach P, Dubied A, Beer JH, et al. Recognition and management of potential drug-drug interactions in
patients on internal medicine wards. Eur J Clin Pharmacol. 2007;63(11):1075-83.
https://psnet.…
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psnet.ahrq.gov/node/35971/psn-pdf
May 27, 2011 - Effectiveness of computerized provider order entry with
dose range checking on prescribing errors.
May 27, 2011
Boling B, McKibben M, Hingl J, et al. Effectiveness of Computerized Provider Order Entry with Dose Range
Checking on Prescribing Errors. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215339.03807.fd.
…
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psnet.ahrq.gov/node/43066/psn-pdf
December 10, 2014 - Reminder: pay attention to the appearance of your
medicines.
December 10, 2014
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
This newsletter article describes an incident involving a patient who noticed that the tabl…
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psnet.ahrq.gov/issue/contemporary-view-medication-related-harm-new-paradigm
July 20, 2012 - July 12, 2010
Medication incident recovery and prevention utilising an Australian community … pharmacy incident reporting system: the QUMwatch study.