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psnet.ahrq.gov/issue/paralyzed-mistakes-preventing-errors-neuromuscular-blocking-agents
June 10, 2018 - Newspaper/Magazine Article
Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.
Citation Text:
Paralyzed by mistakes: preventing errors with neuromuscular blocking agents. ISMP Medication Safety Alert! Acute Care Edition. September 22, 2005;10:1-3.
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psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
June 10, 2018 - Newspaper/Magazine Article
Administering a saline flush "site unseen" can lead to a wrong route error.
Citation Text:
Administering a saline flush "site unseen" can lead to a wrong route error. ISMP Medication Safety Alert! Acute care edition. May 16, 2013;18:1-3.
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psnet.ahrq.gov/issue/distractions-and-their-impact-patient-safety
September 27, 2016 - Newspaper/Magazine Article
Distractions and their impact on patient safety.
Citation Text:
Distractions and their impact on patient safety. Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10.
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psnet.ahrq.gov/issue/differentiating-close-calls-errors-multidisciplinary-perspective
February 09, 2011 - Study
Differentiating close calls from errors: a multidisciplinary perspective.
Citation Text:
Differentiating close calls from errors: a multidisciplinary perspective. Etchegaray JM; Thomas EJ; Geraci JM; Simmons D; Martin SK.
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psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons
May 29, 2019 - Book/Report
Avoiding Unconscious Bias: a Guide for Surgeons.
Citation Text:
Avoiding Unconscious Bias: a Guide for Surgeons. London, UK: Royal College of Surgeons of England; 2016.
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psnet.ahrq.gov/issue/medical-errors-dentistry
September 18, 2013 - Newspaper/Magazine Article
Medical errors in dentistry.
Citation Text:
Medical errors in dentistry. Nagelberg R. RDH. September 2015;35:79-85.
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psnet.ahrq.gov/issue/how-hepatitis-probe-led-clinic-old-fashioned-legwork-yielded-clues-came-together
September 01, 2011 - Newspaper/Magazine Article
How hepatitis probe led to clinic: old-fashioned legwork yielded clues that came together.
Citation Text:
How hepatitis probe led to clinic: old-fashioned legwork yielded clues that came together. Allen M. Las Vegas Sun. March 2, 2008.
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psnet.ahrq.gov/issue/sway-unravelling-unconscious-bias
August 02, 2016 - Book/Report
Sway: Unravelling Unconscious Bias
Citation Text:
Sway: Unravelling Unconscious Bias Agarwal P. London, UK: Bloomsbury Sigma; 2020. ISBN 9781472971357.
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psnet.ahrq.gov/issue/challenges-ahead-technology-training-report-training-initiative-committee-technology
August 09, 2017 - Newspaper/Magazine Article
Challenges ahead in technology training: a report on the training initiative of the Committee on Technology.
Citation Text:
Challenges ahead in technology training: a report on the training initiative of the Committee on Technology. Olympio MA; Reinke B; Ab…
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psnet.ahrq.gov/issue/hard-look-hard-stops-and-workarounds-acute-care-setting
June 26, 2013 - Newspaper/Magazine Article
A hard look at hard stops and workarounds in the acute care setting.
Citation Text:
A hard look at hard stops and workarounds in the acute care setting. ISMP Medication Safety Alert! Acute care edition. June 29, 2023;28(13);1-4.
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psnet.ahrq.gov/issue/i-cant-turn-my-brain
December 14, 2016 - Newspaper/Magazine Article
I can't turn my brain off.
Citation Text:
I can't turn my brain off. Hoffman J. New York Times. May 16, 2020.
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psnet.ahrq.gov/issue/zero-eliminating-unnecessary-deaths-post-pandemic-nhs
August 06, 2016 - Book/Report
Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.
Citation Text:
Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS. Hunt J. London, UK: Swift Press; 2022. ISBN: 9781800751224.
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psnet.ahrq.gov/issue/icn-position-statement-patient-safety
March 09, 2022 - Organizational Policy/Guidelines
ICN Position Statement: Patient Safety.
Citation Text:
ICN Position Statement: Patient Safety. Geneva, Switzerland; International Council of Nurses: 2023.
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psnet.ahrq.gov/issue/handoff-communication
October 16, 2019 - Special or Theme Issue
Handoff Communication.
Citation Text:
Handoff Communication. APSF Newsletter. October 2017;32:29-56.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0543_05-24-2013.pdf
January 01, 2013 - TND-0543_05-24-2013
Acute Cough Illness
Nomination Summary Document
Results of Topic Selection Process & Next Steps
Acute Cough Illness (ACI) will go for…
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psnet.ahrq.gov/issue/exploring-costs-unsafe-care-nhs-report-prepared-department-health
July 10, 2019 - Book/Report
Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health.
Citation Text:
Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health. London, UK: Frontier Economics Ltd; October 2014.
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psnet.ahrq.gov/issue/complaints-and-raising-concerns
November 16, 2015 - Book/Report
Complaints and Raising Concerns.
Citation Text:
Complaints and Raising Concerns. Fourth Report of Session 2014–15. House of Commons Health Committee. London, England: The Stationery Office; January 13, 2015. Publication HC 350.
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs022586-lacson-final-report-2017.pdf
January 01, 2017 - follow-up
recommendations to ambulatory primary care physicians (PCP) on timely implementation of
recommended … documented communication of critical results between
caregivers, a deficit remained in adherence to recommended … Specific Aim 2: Evaluate the impact of the system on timely implementation of recommended
follow-up … an explicit radiologist recommendation was a significant predictor
(p<0.05) for completion of the recommended … A secondary outcome is
the rate of completion of the recommended follow-up exam.
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cds.ahrq.gov/sites/default/files/cds/artifact/396/cap_3_DecidExecut.html
January 01, 1970 - recommendation; Reason: Logic: Conditional: Direct admission to an ICU or high-level monitoring unit is recommended … Cost: Recommendation Recommended diagnostic tests for etiology.
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cds.ahrq.gov/sites/default/files/cds/artifact/711/Anthrax_Post_Exposure_Prophylaxis_CDS_Validation_Report.pdf
October 17, 2018 - Logic encoded into the CDS determines the patient-
specific recommended treatment and can also provide … Either there is an indication that the recommended dosing
sequence was not followed (i.e., there is … OrderSet PlanDefinition
(STU3)
The order set containing the recommended treatment for
Anthrax PEP … It references the ActionList and the
ContainedResourcesList, which contain the recommended
treatments … If treatment is not recommended, then
this resource will be empty.