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  1. Managing risk during transition to new ISO tubing connector standards. | PSNet

    psnet.ahrq.gov/issue/managing-risk-during-transition-new-iso-tubing-connector-standards
    December 23, 2016 - Sentinel Event Alerts Managing risk during transition to new ISO tubing connector standards. Citation Text: Managing risk during transition to new ISO tubing connector standards. Sentinel Event Alert. August 20, 2014;(53):1-6. Copy Citation Save Save to your libra…

  2. Building a high-reliability organization: one system's patient safety journey. | PSNet

    psnet.ahrq.gov/issue/building-high-reliability-organization-one-systems-patient-safety-journey
    November 23, 2005 - Commentary Building a high-reliability organization: one system's patient safety journey. Citation Text: Building a high-reliability organization: one system's patient safety journey. J Healthc Manag. 2017;62. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndN…

  3. Learning from Investigations. | PSNet

    psnet.ahrq.gov/issue/learning-investigations
    July 28, 2013 - Book/Report Learning from Investigations. Citation Text: Learning from Investigations. Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN 9781845621636. Copy Citation Save Save to your library Print Downlo…

  4. Radiation Oncology Incident Learning System. | PSNet

    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. Copy Citation Save Save to your library Pri…

  5. Health IT Safety Center Roadmap. | PSNet

    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. Copy Citation Save Save to your library P…

  6. Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely. | PSNet

    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…

  7. WebAIRS Anesthesia Incident Reporting System. | PSNet

    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. Copy Citation Save Save to your library Print Download PDF …

  8. Sterile compounding tragedy is a symptom of a broken system on many levels. | PSNet

    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.   Copy C…

  9. Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. | PSNet

    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. Copy …

  10. Positive Patient Identification. | PSNet

    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. Copy Citation Save Save to your library …

  11. Nursing Home Complaint Investigations.  | PSNet

    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. Copy Citation Save Save to your library Print …

  12. Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. | PSNet

    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…

  13. Learning From Serious Failings in Care: Main Report. | PSNet

    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. Copy Citation …

  14. Final Report of the Commission on Care. | PSNet

    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. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  15. Physician assistants and the disclosure of medical error. | PSNet

    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. Copy Citation Format: DOI Google…

  16. To Err Is Human — To Delay Is Deadly. | PSNet

    psnet.ahrq.gov/issue/err-human-delay-deadly
    July 11, 2017 - Book/Report To Err Is Human — To Delay Is Deadly. Citation Text: To Err Is Human — To Delay Is Deadly. Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009. Copy Citation Save Save to your library Print Download PDF Share Facebook …

  17. 20 years later: to err is a leadership failure. | PSNet

    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. Copy Citation Save Save to your library P…

  18. Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community. | PSNet

    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 …

  19. Cap 3 Decidexecut

    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. CAMH_Template_Long_Instructions (pdf file)

    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.
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