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  1. psnet.ahrq.gov/issue/alert-reports-severe-harm-after-intravenous-administration-breast-milk-infants
    May 02, 2018 - Newspaper/Magazine Article ALERT: reports of severe harm after intravenous administration of breast milk to infants. Citation Text: ALERT: reports of severe harm after intravenous administration of breast milk to infants. ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.   …
  2. psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
    February 06, 2019 - Fact Sheet/FAQs 10 Medication Safety Tips for Hospitalized Patients. Citation Text: 10 Medication Safety Tips for Hospitalized Patients. Horsham, PA: Institute for Safe Medication Practices; 2019. Copy Citation Save Save to your library Print Download PD…
  3. psnet.ahrq.gov/issue/ismp-list-high-alert-medications-communityambulatory-healthcare
    December 15, 2021 - Fact Sheet/FAQs ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. Citation Text: ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. Horsham, PA: Institute for Safe Medication Practices; 2021. Copy Citation Save Save to yo…
  4. psnet.ahrq.gov/issue/canadian-disclosure-guidelines-being-open-and-honest-patients-and-families
    September 08, 2010 - Book/Report Canadian Disclosure Guidelines: Being Open and Honest with Patients and Families. Citation Text: Canadian Disclosure Guidelines: Being Open and Honest with Patients and Families. Disclosure Working Group. Edmonton, AB, Canada; Canadian Patient Safety Institute; 2011. ISBN 978…
  5. psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors
    May 02, 2018 - Newspaper/Magazine Article Misprogramming PCA concentration leads to dosing errors. Citation Text: Misprogramming PCA concentration leads to dosing errors. ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3. Copy Citation Save Save t…
  6. psnet.ahrq.gov/issue/benefits-and-risks-including-patients-rca-teams
    May 02, 2018 - Newspaper/Magazine Article Benefits and risks of including patients on RCA teams. Citation Text: Benefits and risks of including patients on RCA teams. ISMP Medication Safety Alert! Acute Care Edition. June 5, 2008;13:1-3. Copy Citation Save Save to your library …
  7. psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route
    December 19, 2016 - Government Resource Oral medications inadvertently given via the intravenous route. Citation Text: Oral medications inadvertently given via the intravenous route. Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91. Copy Citation Save …
  8. psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results
    November 13, 2019 - Newspaper/Magazine Article Advancing safety with closed-loop communication of test results. Citation Text: Advancing safety with closed-loop communication of test results. Quick Safety. December 17, 2019;(52):1-3. Copy Citation Save Save to your library …
  9. psnet.ahrq.gov/issue/conversation-patient-safety-officers
    April 30, 2024 - Book/Report A Conversation with Patient Safety Officers. Citation Text: A Conversation with Patient Safety Officers. Harrisburg, PA: Patient Safety Authority; 2007. Copy Citation Save Save to your library Print Download PDF Share Facebook…
  10. digital.ahrq.gov/ahrq-funded-projects/electronic-health-record-information-design-and-usability-toolkit
    January 01, 2023 - Electronic Health Record Information Design and Usability Toolkit Project Final Report ( PDF , 1.03 MB) × Disclaimer Disclaimer details Close Project Description Annual Summaries Publications Project Details - …
  11. psnet.ahrq.gov/issue/partnering-patients-and-families-enhance-safety-and-quality-mini-toolkit
    September 12, 2018 - Toolkit Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit. Citation Text: Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit. Bethesda, MD: Institute for Patient- and Family-Centered Care; 2011. Copy Citation …
  12. psnet.ahrq.gov/issue/toward-improving-outcome-pregnancy-enhancing-perinatal-health-through-quality-safety-and
    June 24, 2015 - Book/Report Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (TIOP III). Citation Text: Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (T…
  13. psnet.ahrq.gov/issue/pain-wrong-site-surgery
    November 28, 2016 - Newspaper/Magazine Article The pain of wrong site surgery. Citation Text: The pain of wrong site surgery. Boodman SG. Washington Post. June 21, 2011:E1. Copy Citation Save Save to your library Print Download PDF Share Facebook Twit…
  14. psnet.ahrq.gov/issue/shining-glaring-light-surgery-technology-records-every-move-aims-improve-safety
    January 29, 2020 - Newspaper/Magazine Article Shining a glaring light on surgery: technology that records every move aims to improve safety. Citation Text: Shining a glaring light on surgery: technology that records every move aims to improve safety. Freyer FJ. Boston Globe. January 13, 2024. Copy Cita…
  15. www.ahrq.gov/news/newsroom/case-studies/201530.html
    November 01, 2015 - Research Medical Center Develops Video to Encourage Continued Use of TeamSTEPPS® Search All Impact Case Studies November 2015 The Graduate Nurse Residency Program at Research Medical Center in Kansas City, Missouri, created a video highlighting nine concepts of AHRQ's TeamSTEPPS® program as a way to re-…
  16. psnet.ahrq.gov/issue/burnout-crisis-american-medicine
    September 03, 2014 - Newspaper/Magazine Article The burnout crisis in American medicine. Citation Text: The burnout crisis in American medicine. Xu R. The Atlantic. May 11, 2018. Copy Citation Save Save to your library Print Download PDF Share Facebook Twit…
  17. psnet.ahrq.gov/issue/pearls-pitfalls-and-errors-musculoskeletal-diagnosis
    February 26, 2025 - Special or Theme Issue Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis. Citation Text: Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis. Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203(3):476-593. Copy Citation Save Save to your library …
  18. 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.
  19. 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.
  20. 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.