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psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors-may-slip-through
June 24, 2020 - Newspaper/Magazine Article
Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks.
Citation Text:
Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks. O'Donnell J. USA Today. September 8, 2020
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Misread Label
November 1, 2003
Franklin BD. Misread Label. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/misread-label
The Case
An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine
[Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - The federal government, states, and territories partnered with multiple national and independent
pharmacies … The pharmacies facilitated vaccinations for NH residents
and staff at no cost to the NHs.76 The CDC
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psnet.ahrq.gov/issue/role-communication-paediatric-drug-safety
July 08, 2008 - Review
The role of communication in paediatric drug safety.
Citation Text:
Stebbing C, Wong ICK, Kaushal R, et al. The role of communication in paediatric drug safety. Arch Dis Child. 2007;92(5):440-5.
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Google Scholar PubMed BibTeX EndNote X3 XML EndN…
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psnet.ahrq.gov/issue/patient-experience-patient-safety-and-provider-well-being-associations-and-paths-quality
January 10, 2024 - Meeting/Conference Proceedings
Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths for Quality Improvement.
Citation Text:
Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths for Quality Improvement. Rockville, MD: Agency fo…
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psnet.ahrq.gov/issue/effects-work-shift-or-shift-length-radiation-safety-perception
August 23, 2023 - Study
Effects of work shift or shift length on radiation safety perception.
Citation Text:
Effects of work shift or shift length on radiation safety perception. Moore QT, Bruno MA. Radiol Technol. 2023;94(6):409-418.
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…
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psnet.ahrq.gov/issue/designing-decision-support-insulin-ordering-computerized-provider-order-entry-system
March 09, 2011 - Study
Designing decision support for insulin ordering in a computerized provider order entry system.
Citation Text:
Wright L, Feldott CC, Hargrove FR. Designing Decision Support for Insulin Ordering in a Computerized Provider Order Entry System. Hosp Pharm. 2010;42(2). doi:10.1310/hpj4…
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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/cultivate-discussions-psychologically-safe-workplace-part-1-and-part-ii
August 11, 2021 - Special or Theme Issue
Cultivate discussions in a psychologically safe workplace: part 1 and part II.
Citation Text:
Cultivate discussions in a psychologically safe workplace: part 1 and part II. ISMP Medication Safety Alert! Acute Care. July 11, 2024;29;(14):1-3; July 25, 2024;29(15):1-…
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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/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - Study
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
Citation Text:
Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26.
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…
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psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
January 12, 2011 - Study
Medication prescribing errors involving the route of administration.
Citation Text:
Lesar TS. Medication Prescribing Errors Involving the Route of Administration. Hosp Pharm. 2010;41(11):1053-1066. doi:10.1310/hpj4111-1053.
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psnet.ahrq.gov/issue/maalox-total-relief-and-maalox-liquid-products-medication-use-errors
February 17, 2021 - Press Release/Announcement
Maalox Total Relief and Maalox Liquid Products: Medication Use Errors.
Citation Text:
Maalox Total Relief and Maalox Liquid Products: Medication Use Errors. MedWatch Safety Alert. Rockville, MD: US Food and Drug Administration; February 17, 2010.
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psnet.ahrq.gov/issue/mix-ups-between-epidural-analgesia-and-iv-antibiotics-labor-and-delivery-units-continue-cause
January 24, 2018 - Newspaper/Magazine Article
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
Citation Text:
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. ISMP Medication Safety Alert! Acut…
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psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future
February 24, 2016 - Newspaper/Magazine Article
Is an indication-based prescribing system in our future?
Citation Text:
Is an indication-based prescribing system in our future? ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.
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psnet.ahrq.gov/issue/improving-care-transitions-optimizing-medication-reconciliation
June 17, 2014 - Commentary
Improving care transitions: optimizing medication reconciliation.
Citation Text:
Association AP, Pharmacists AS of H-S, Steeb D, et al. Improving care transitions: optimizing medication reconciliation. J Am Pharm Assoc (2003). 2012;52(4):e43-e52. doi:10.1331/JAPhA.2012.12527…
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psnet.ahrq.gov/issue/start-year-right-addressing-these-top-10-medication-safety-concerns-2021
April 20, 2022 - Newspaper/Magazine Article
Start the year off right by addressing these top 10 medication safety concerns from 2021.
Citation Text:
Start the year off right by addressing these top 10 medication safety concerns from 2021. ISMP Medication Safety Alert! Acute care edition. January 27, 2022…
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psnet.ahrq.gov/issue/families-are-struggling-use-medicines-home-we-must-truly-involve-them-their-own-safety
February 02, 2022 - Newspaper/Magazine Article
Families are struggling to use medicines at home — we must truly involve them in their own safety.
Citation Text:
Families are struggling to use medicines at home — we must truly involve them in their own safety. Morris S, O’Hara J. Pharmacuetical Journal.…