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psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
October 07, 2020 - Book/Report
Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.
Citation Text:
Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.
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psnet.ahrq.gov/issue/disclosing-adverse-events-you-said-it-now-write-it
July 14, 2010 - Commentary
Disclosing adverse events: you said it, now write it.
Citation Text:
Monson MS. Disclosing adverse events: you said it, now write it. Nurs Manage. 2006;37(8):16-7, 55.
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psnet.ahrq.gov/issue/mobilising-team-who-surgical-safety-checklist-qualitative-video-study
September 29, 2017 - Study
Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study.
Citation Text:
Korkiakangas T. Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. BMJ Qual Saf. 2017;26(3):177-188. doi:10.1136/bmjqs-2015-004887.
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - healthcare team huddles to discuss patient issues and family concerns, observations of rounds to ensure
proper
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psnet.ahrq.gov/issue/partnering-families-and-patient-advocates-another-line-defense-adverse-event-surveillance
September 11, 2019 - Newspaper/Magazine Article
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
Citation Text:
Partnering with families and patient advocates: another line of defense in adverse event surveillance. ISMP Medication Safety Alert! Acute Care…
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psnet.ahrq.gov/issue/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety
September 07, 2022 - Newspaper/Magazine Article
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.
Citation Text:
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. ISMP Medication Safety Alert! Acut…
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psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrectly-using-insulin-pens-home
December 15, 2021 - Press Release/Announcement
Severe hyperglycemia in patients incorrectly using insulin pens at home.
Citation Text:
Severe hyperglycemia in patients incorrectly using insulin pens at home. National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American…
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psnet.ahrq.gov/issue/pc-standards-maternal-safety
September 06, 2017 - Newspaper/Magazine Article
PC standards for maternal safety.
Citation Text:
PC standards for maternal safety. The Joint Commission. R3 Report. August 21, 2019;24:1-6.
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psnet.ahrq.gov/issue/our-long-journey-towards-safety-minded-just-culture-part-i-where-weve-been
November 13, 2018 - Newspaper/Magazine Article
Our long journey towards a safety-minded just culture. Part I: Where we've been.
Citation Text:
Our long journey towards a safety-minded just culture. Part I: Where we've been. ISMP Medication Safety Alert! Acute care edition. September 7, 2006;11.
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - The
physicians who reviewed his medical record judged that proper diagnostic management might have
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psnet.ahrq.gov/issue/nonfatal-unintentional-medication-exposures-among-young-children-united-states-2001-2003
February 27, 2019 - Government Resource
Nonfatal, unintentional medication exposures among young children—United States, 2001–2003.
Citation Text:
Prevention C for DC and. Nonfatal, unintentional medication exposures among young children--United States, 2001-2003. MMWR Morb Mortal Wkly Rep. 2006;55(1):1-5…
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psnet.ahrq.gov/web-mm/language-barrier
February 28, 2024 - The pharmacist attempted to demonstrate proper dosing and administration using the medication dropper … At the time of discharge from the hospital, the nurse counseled the parents on proper dosing through
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - BB: Certainly, proper staffing is a huge issue. … But, in saying that we believe there is a better way to do it, we still believe ratios are proper.
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - BB: Certainly, proper staffing is a huge issue. … But, in saying that we believe there is a better way to do it, we still believe ratios are proper.
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - rate and faster identification of complications are compelling benefits of using ultrasound guidance, proper … Access to ultrasound does not guarantee its proper use or the competence of a provider, but it can reduce
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psnet.ahrq.gov/issue/iv-push-gap-analysis-tool-gat-helps-uncover-national-priorities-safe-injection-practices
August 14, 2019 - Newspaper/Magazine Article
IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices.
Citation Text:
IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. ISMP Medication Safety Alert! Acute Care Edition. Augu…
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psnet.ahrq.gov/issue/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular-blocker
June 19, 2019 - Newspaper/Magazine Article
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
Citation Text:
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. ISMP Medication Safety Alert! Acute Ca…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Baxter Mini-Bag Plus system.( 6-9 ) Carbamazepine is not the only potentially toxic medication in which proper
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - In order to prevent future errors, the proper
recording of the vaccine, date, and lot number are vital