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psnet.ahrq.gov/issue/analysis-reported-drug-interactions-recipe-harm-patients
January 20, 2016 - Newspaper/Magazine Article
Analysis of reported drug interactions: a recipe for harm to patients.
Citation Text:
Analysis of reported drug interactions: a recipe for harm to patients. Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148.
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psnet.ahrq.gov/issue/new-2012-national-patient-safety-goal-catheter-associated-urinary-tract-infection-cauti
February 28, 2018 - Organizational Policy/Guidelines
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).
Citation Text:
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI). Joint Commission.
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psnet.ahrq.gov/issue/increasing-patient-safety-and-surgical-team-communication-using-counttime-out-board
February 22, 2012 - Commentary
Increasing patient safety and surgical team communication by using a count/time out board.
Citation Text:
Edel EM. Increasing patient safety and surgical team communication by using a count/time out board. AORN J. 2010;92(4):420-4. doi:10.1016/j.aorn.2010.03.013.
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psnet.ahrq.gov/issue/ismp-survey-provides-insights-preparation-and-admixture-practices-outside-pharmacy
December 02, 2020 - Newspaper/Magazine Article
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.
Citation Text:
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. ISMP Medication Safety Alert! Acute care edition. November 5…
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psnet.ahrq.gov/issue/death-and-neurological-devastation-intrathecal-vinca-alkaloids-prepared-syringes-120-prepared
June 10, 2018 - Newspaper/Magazine Article
Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0.
Citation Text:
Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0. …
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psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
November 21, 2018 - Newspaper/Magazine Article
I-PASS checklist: a powerful tool for patient handoffs.
Citation Text:
I-PASS checklist: a powerful tool for patient handoffs. Peeples L. Pharmacy Practice News. October 10, 2018.
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psnet.ahrq.gov/issue/potassium-may-no-longer-be-stocked-patient-care-units-serious-threats-still-exist
May 02, 2018 - Newspaper/Magazine Article
Potassium may no longer be stocked on patient care units, but serious threats still exist!
Citation Text:
Potassium may no longer be stocked on patient care units, but serious threats still exist! ISMP Medication Safety Alert! Acute care edition. October 4, 200…
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psnet.ahrq.gov/issue/former-pharmacist-indicted-manslaughter-after-med-error
October 17, 2018 - Newspaper/Magazine Article
Former pharmacist indicted for manslaughter after med error.
Citation Text:
Former pharmacist indicted for manslaughter after med error. Paul R. Drug Topics. September 17, 2007.
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psnet.ahrq.gov/issue/another-tragic-parenteral-nutrition-compounding-error
June 10, 2018 - Newspaper/Magazine Article
Another tragic parenteral nutrition compounding error.
Citation Text:
Another tragic parenteral nutrition compounding error. ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
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psnet.ahrq.gov/issue/eliminating-racial-and-ethnic-disparities-causing-mortality-and-morbidity-pregnant-and
December 23, 2016 - Sentinel Event Alerts
Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients.
Citation Text:
Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients. Sentinel Event Alert. January…
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psnet.ahrq.gov/issue/safe-practices-better-healthcare-2006-update
September 06, 2011 - Book/Report
Safe Practices for Better Healthcare: 2006 Update.
Citation Text:
Safe Practices for Better Healthcare: 2006 Update. Washington DC: National Quality Forum; 2007.
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psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-anesthesia
July 25, 2018 - Organizational Policy/Guidelines
APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.
Citation Text:
APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. The APSF Committee on Technology. APSF Newsletter.&n…
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psnet.ahrq.gov/issue/safe-handling-hazardous-drugs
January 02, 2011 - Clinical Guideline
Safe Handling of Hazardous Drugs.
Citation Text:
Safe Handling of Hazardous Drugs. Polovich M; Blecher CS; Glynn-Tucker EM; McDiarmid M; Newton SA
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psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
June 10, 2018 - Newspaper/Magazine Article
ISMP updates its list of drug name pairs with Tall man letters.
Citation Text:
ISMP updates its list of drug name pairs with Tall man letters. ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.
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psnet.ahrq.gov/issue/normalization-deviance-what-are-perioperative-risks
July 15, 2020 - Commentary
The normalization of deviance: what are the perioperative risks?
Citation Text:
McNamara SA. The normalization of deviance: what are the perioperative risks? AORN J. 2011;93(6):796-801. doi:10.1016/j.aorn.2011.02.009.
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psnet.ahrq.gov/issue/sorry-works-20-disclosure-apology-and-relationships-prevent-medical-malpractice-claims
November 30, 2007 - Book/Report
Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims.
Citation Text:
Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims. Wojcieszak D, Saxton JW, Finkelstein MM. Bloomington, IN: AuthorHouse; …
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
May 27, 2020
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
The Case
An infant with trisomy 21 underwent repair of a…
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Suicidal Man With Gun
Citation Text:
Simon RI. Suicidal Man With Gun. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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