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psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
April 22, 2020 - Multi-use Website
Radiation Oncology Incident Learning System.
Citation Text:
Radiation Oncology Incident Learning System. American Society for Radiation Oncology and American Association of Physicists in Medicine.
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psnet.ahrq.gov/issue/health-it-safety-center-roadmap
June 29, 2016 - Government Resource
Health IT Safety Center Roadmap.
Citation Text:
Health IT Safety Center Roadmap. RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015.
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psnet.ahrq.gov/issue/implementing-patient-safety-addressing-culture-conditions-and-values-help-people-work-safely
October 18, 2017 - Book/Report
Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely.
Citation Text:
Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely. Woodward, S. 1st ed. New York, NY: Taylor & Francis Group; Sept…
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psnet.ahrq.gov/issue/webairs-anesthesia-incident-reporting-system
November 10, 2011 - Multi-use Website
WebAIRS Anesthesia Incident Reporting System.
Citation Text:
WebAIRS Anesthesia Incident Reporting System. Australian and New Zealand Tripartite Anaesthetic Data Committee.
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psnet.ahrq.gov/issue/sterile-compounding-tragedy-symptom-broken-system-many-levels
February 13, 2019 - Newspaper/Magazine Article
Sterile compounding tragedy is a symptom of a broken system on many levels.
Citation Text:
Sterile compounding tragedy is a symptom of a broken system on many levels. ISMP Medication Safety Alert! Acute Care Edition. October 18, 2012;17:1-4.
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psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections
June 10, 2018 - Newspaper/Magazine Article
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.
Citation Text:
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. ISMP Medication Safety Alert! Acute care edition. July 26, 2007.
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psnet.ahrq.gov/issue/positive-patient-identification
June 19, 2024 - Book/Report
Positive Patient Identification.
Citation Text:
Positive Patient Identification. Healthcare Safety Investigation Branch (HSIB), Dorset, UK: Health Services Safety Investigations Body; February 2024.
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psnet.ahrq.gov/issue/nursing-home-complaint-investigations
September 27, 2006 - Government Resource
Nursing Home Complaint Investigations.
Citation Text:
Nursing Home Complaint Investigations. Levinson DR. Washington DC: Office of the Inspector General; July 2006. OEI-01-04-00340.
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psnet.ahrq.gov/issue/tragic-error-neuromuscular-blocker-should-prompt-risk-assessment-all-hospitals
November 16, 2015 - Newspaper/Magazine Article
Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.
Citation Text:
Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. ISMP Medication Safety Alert! Acute Care Edition. December 18, 2014;19…
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psnet.ahrq.gov/issue/learning-serious-failings-care-main-report
August 23, 2017 - Book/Report
Learning From Serious Failings in Care: Main Report.
Citation Text:
Learning From Serious Failings in Care: Main Report. Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Academy of Medical Royal Colleges and Faculties in Scotland; May 2015.
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psnet.ahrq.gov/issue/final-report-commission-care
September 29, 2017 - Book/Report
Final Report of the Commission on Care.
Citation Text:
Final Report of the Commission on Care. Washington, DC: Commission on Care; June 2016.
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psnet.ahrq.gov/issue/2006-update-consumers-views-patient-safety-and-quality-information
July 28, 2013 - Multi-use Website
2006 Update on Consumers' Views of Patient Safety and Quality Information.
Citation Text:
2006 Update on Consumers' Views of Patient Safety and Quality Information. Washington DC: Kaiser Family Foundation; 2006.
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psnet.ahrq.gov/issue/physician-assistants-and-disclosure-medical-error
May 11, 2016 - Commentary
Physician assistants and the disclosure of medical error.
Citation Text:
Brock DM, Quella A, Lipira L, et al. Physician assistants and the disclosure of medical error. Acad Med. 2014;89(6):858-62. doi:10.1097/ACM.0000000000000261.
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psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
January 15, 2020 - Newspaper/Magazine Article
Proactive prevention of maternal death from maternal hemorrhage.
Citation Text:
Proactive prevention of maternal death from maternal hemorrhage. Quick Safety. October 29, 2019;(51):1-3.
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psnet.ahrq.gov/issue/20-years-later-err-leadership-failure
November 30, 2016 - Special or Theme Issue
20 years later: to err is a leadership failure.
Citation Text:
20 years later: to err is a leadership failure. Castellucci M, Meyer H. Modern Healthcare: November 11, 2019;49:18-22;28-30;32-34.
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psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
September 26, 2016 - Newspaper/Magazine Article
Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.
Citation Text:
Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community. ISMP Medication Safety Alert! Acute …
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psnet.ahrq.gov/issue/side-tracks-safety-express-interruptions-lead-errors-and-unfinishedwait-what-was-i-doing
June 10, 2018 - Newspaper/Magazine Article
Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?
Citation Text:
Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? ISMP Medication Safety Alert! Acute care…
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psnet.ahrq.gov/issue/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry-errors
June 10, 2018 - Newspaper/Magazine Article
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.
Citation Text:
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. ISMP Medication Safety Alert! Acute care…
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psnet.ahrq.gov/issue/learning-errors-new-covid-19-vaccines
October 21, 2021 - Newspaper/Magazine Article
Learning from errors with the new COVID-19 vaccines.
Citation Text:
Learning from errors with the new COVID-19 vaccines. ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.
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psnet.ahrq.gov/issue/your-high-alert-medication-list-relatively-useless-without-associated-risk-reduction
May 07, 2014 - Newspaper/Magazine Article
Your high-alert medication list—relatively useless without associated risk-reduction strategies.
Citation Text:
Your high-alert medication list—relatively useless without associated risk-reduction strategies. ISMP Medication Safety Alert! Acute Care Edition. Ap…