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psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-codes
November 02, 2022 - Newspaper/Magazine Article
Survey results from pharmacists provide support to enhance the organizational response to codes.
Citation Text:
Survey results from pharmacists provide support to enhance the organizational response to codes. ISMP Medication Safety Alert! Acute care edition. Oc…
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psnet.ahrq.gov/issue/preventing-communication-errors-telephone-medicine
December 01, 2004 - Commentary
Preventing communication errors in telephone medicine.
Citation Text:
Reisman AB, Brown KE. Preventing communication errors in telephone medicine. J Gen Intern Med. 2005;20(10):959-63.
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psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-system-innovation-concord-hospital
October 19, 2022 - Commentary
John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital.
Citation Text:
Uhlig PN, Brown J, Nason AK, et al. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672.
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psnet.ahrq.gov/issue/electronically-generated-medication-administration-and-electronic-medication-administration
May 25, 2016 - Book/Report
Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.
Citation Text:
Electronically Generated Medication Administration and Electr…
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psnet.ahrq.gov/issue/more-can-be-done-alleviate-errors-associated-pharmaceutical-product-labeling-and-packaging
May 03, 2023 - Newspaper/Magazine Article
More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.
Citation Text:
More can be done to alleviate errors associated with pharmaceutical product labeling and packaging. ISMP Medication Safety Alert! Acute Care Editi…
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psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-and-packaging
March 10, 2021 - Newspaper/Magazine Article
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.
Citation Text:
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. ISMP Medication Safety Alert! Acute ca…
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psnet.ahrq.gov/issue/missed-or-rationed-nursing-care
February 12, 2020 - Special or Theme Issue
Missed or Rationed Nursing Care.
Citation Text:
Missed or Rationed Nursing Care. J Nurs Manag. 2020;28(8): i-iv, 1767-2275.
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psnet.ahrq.gov/issue/im-er-doctor-heres-what-i-found-when-i-asked-chatgpt-diagnose-my-patients
November 06, 2012 - Newspaper/Magazine Article
I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.
Citation Text:
I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients. Tamayo-Sarver J. Fast Company. March 13, 2023.
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psnet.ahrq.gov/issue/medication-without-harm-how-digital-healthcare-tools-can-support-providers-and-improve
July 22, 2024 - Meeting/Conference Proceedings
Medication Without Harm - How Digital Healthcare Tools Can Support Providers and Improve Patient Safety.
Citation Text:
Medication Without Harm - How Digital Healthcare Tools Can Support Providers and Improve Patient Safety. Agency for Healthcare Research a…
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psnet.ahrq.gov/issue/blind-obedience-and-unnecessary-workup-hypoglycemia-teachable-moment
March 14, 2022 - Commentary
Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment.
Citation Text:
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.71…
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/issue/important-information-safe-use-tussionex-pennkinetic-extended-release-suspension
February 15, 2024 - Government Resource
Important information for the safe use of Tussionex Pennkinetic Extended-Release Suspension.
Citation Text:
Important information for the safe use of Tussionex Pennkinetic Extended-Release Suspension. FDA Consumer Health Information. Silver Spring, MD: US Food and…
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psnet.ahrq.gov/issue/preventing-surgical-site-infections-implementing-strategies-throughout-perioperative
January 15, 2025 - Commentary
Preventing surgical site infections: implementing strategies throughout the perioperative continuum.
Citation Text:
Rosa R, Sposato K, Abbo LM. Preventing surgical site infections: implementing strategies throughout the perioperative continuum. AORN J. 2023;117(5):300-311. doi…
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psnet.ahrq.gov/issue/addressing-medicines-bias-against-patients-who-are-overweight
May 15, 2019 - Commentary
Addressing medicine's bias against patients who are overweight.
Citation Text:
Rubin R. Addressing Medicine's Bias Against Patients Who Are Overweight. JAMA. 2019;321(10):925-927. doi:10.1001/jama.2019.0048.
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psnet.ahrq.gov/issue/ensuring-competency-and-safety-when-onboarding-newly-hired-professional-staff
February 22, 2023 - Newspaper/Magazine Article
Ensuring competency and safety when onboarding newly hired professional staff.
Citation Text:
Ensuring competency and safety when onboarding newly hired professional staff. ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;…
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psnet.ahrq.gov/issue/older-adults-perceptions-feeling-safe-urban-and-rural-acute-care
October 17, 2018 - Study
Older adults' perceptions of feeling safe in urban and rural acute care.
Citation Text:
Lasiter S, Duffy J. Older adults' perceptions of feeling safe in urban and rural acute care. J Nurs Adm. 2013;43(1):30-6. doi:10.1097/NNA.0b013e3182786013.
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psnet.ahrq.gov/issue/potentially-dangerous-confusion-between-bloxiverz-neostigmine-injection-and-vazculep
July 08, 2015 - Press Release/Announcement
Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection.
Citation Text:
Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. National Alert Net…