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psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
November 16, 2022 - Commentary
Surgical 'never events': how common are adverse occurrences?
Citation Text:
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
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psnet.ahrq.gov/issue/alliance-between-society-and-medicine-publics-stake-medical-professionalism
November 16, 2022 - Commentary
Alliance between society and medicine: the public's stake in medical professionalism.
Citation Text:
Cohen JJ, Cruess S, Davidson C. Alliance between society and medicine: the public's stake in medical professionalism. JAMA. 2007;298(6):670-3.
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psnet.ahrq.gov/issue/unsuspected-mr-projectile-wooden-chair-metal-bracing
August 03, 2022 - Commentary
An unsuspected MR projectile: a "wooden" chair with metal bracing.
Citation Text:
Ulaner GA, Colletti PM. An unsuspected MR projectile: A “wooden” chair with metal bracing. Journal of Magnetic Resonance Imaging. 2006;23(5). doi:10.1002/jmri.20573.
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psnet.ahrq.gov/issue/unstoppable-doctor-has-been-investigated-every-level-government-how-he-still-practicing
September 16, 2020 - Newspaper/Magazine Article
Unstoppable: this doctor has been investigated at every level of government. How is he still practicing?
Citation Text:
Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? Waldman A. ProPublica. August…
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psnet.ahrq.gov/issue/reducing-errors-emergency-surgery
January 31, 2018 - Review
Reducing errors in emergency surgery.
Citation Text:
Watters DAK, Truskett PG. Reducing errors in emergency surgery. ANZ J Surg. 2013;83(6):434-437. doi:10.1111/ans.12194.
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - Newspaper/Magazine Article
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go.
Citation Text:
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …
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psnet.ahrq.gov/issue/spike-fatal-medication-errors-beginning-each-month
January 26, 2022 - Study
Spike in fatal medication errors at the beginning of each month.
Citation Text:
Phillips DP, Jarvinen JR, Phillips RR. A spike in fatal medication errors at the beginning of each month. Pharmacotherapy. 2005;25(1):1-9.
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psnet.ahrq.gov/issue/choosing-right-strategy-medication-error-reduction-part-i-and-part-ii
September 24, 2010 - Commentary
Choosing the right strategy for medication error reduction—part I and part II.
Citation Text:
Paparella S. Choosing the Right Strategy for Medication Error Reduction: Part I. J Emerg Nurs. 2008;34(2). doi:10.1016/j.jen.2007.11.011.
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psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery
June 11, 2014 - Review
Concept analysis: wrong-site surgery.
Citation Text:
Watson DS. Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6. doi:10.1016/j.aorn.2015.03.012.
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psnet.ahrq.gov/issue/verbal-medication-orders-or
March 06, 2024 - Commentary
Verbal medication orders in the OR.
Citation Text:
Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9.
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psnet.ahrq.gov/issue/postoperative-complications-due-retained-surgical-sponge
February 23, 2011 - Commentary
Postoperative complications due to a retained surgical sponge.
Citation Text:
Sarda AK, Pandey D, Neogi S, et al. Postoperative complications due to a retained surgical sponge. Singapore Med J. 2007;48(6):e160-4.
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psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
February 01, 2023 - Newspaper/Magazine Article
Assessing medication safety in settings not designated solely for pediatric patients.
Citation Text:
Assessing medication safety in settings not designated solely for pediatric patients. ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5…
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psnet.ahrq.gov/issue/surveillance-strategy-improving-patient-safety-acute-and-critical-care-units
September 27, 2016 - Commentary
Surveillance: a strategy for improving patient safety in acute and critical care units.
Citation Text:
Henneman EA, Gawlinski A, Giuliano KK. Surveillance: A strategy for improving patient safety in acute and critical care units. Crit Care Nurse. 2012;32(2):e9-18. doi:10.403…
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psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-systems-protecting-veterans-clinical-harm
December 23, 2012 - Congressional Testimony
Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm.
Citation Text:
Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. US House of Representatives Committee on Veterans Affairs Subco…
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psnet.ahrq.gov/issue/when-good-doctors-go-bad-systems-problem
November 02, 2014 - Commentary
When good doctors go bad: a systems problem.
Citation Text:
Leape L. When good doctors go bad: a systems problem. Ann Surg. 2006;244(5):649-652.
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psnet.ahrq.gov/issue/getting-surgery-right
February 15, 2011 - Study
Getting surgery right.
Citation Text:
Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg. 2007;246(3):395-403, discussion 403-5.
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psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
May 24, 2017 - Toolkit
National Center for Patient Safety Falls Toolkit 2004.
Citation Text:
National Center for Patient Safety Falls Toolkit 2004. Department of Veterans Affairs (VA) National Center for Patient Safety
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psnet.ahrq.gov/issue/analysis-ismp-national-vaccine-errors-reporting-program-part-1-and-part-2
July 08, 2015 - Newspaper/Magazine Article
Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2.
Citation Text:
Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;…
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psnet.ahrq.gov/issue/survey-shows-room-improvement-three-new-best-practices-hospitals
June 01, 2022 - Newspaper/Magazine Article
Survey shows room for improvement with three new best practices for hospitals.
Citation Text:
Survey shows room for improvement with three new best practices for hospitals. ISMP Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.
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psnet.ahrq.gov/issue/survey-shows-room-improvement-two-new-ismp-targeted-medication-safety-best-practices
February 12, 2020 - Newspaper/Magazine Article
Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.
Citation Text:
Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. ISMP Medication Safety Alert! Acute care edition. July 3…