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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…
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psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-leading-drug
June 10, 2018 - Newspaper/Magazine Article
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.
Citation Text:
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety…
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psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential-prevent-harm
June 10, 2018 - Newspaper/Magazine Article
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
Citation Text:
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. ISMP Medication Safety Alert! Acute Care E…
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psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or
September 14, 2016 - Newspaper/Magazine Article
Accidental IV infusion of heparinized irrigation in the OR.
Citation Text:
Accidental IV infusion of heparinized irrigation in the OR. ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
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psnet.ahrq.gov/issue/medical-monitoring-pharmaceutical-injuries-tort-law-publics-health
May 20, 2015 - Commentary
Medical monitoring for pharmaceutical injuries: tort law for the public's health?
Citation Text:
Studdert DM, Mello MM, Brennan TA. Medical monitoring for pharmaceutical injuries: tort law for the public's health? JAMA. 2003;289(7):889-94.
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psnet.ahrq.gov/issue/still-not-safe-patient-safety-and-middle-managing-american-medicine
June 26, 2019 - Book/Report
Emerging Classic
Still Not Safe: Patient Safety and the Middle-Managing of American Medicine.
Citation Text:
Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. Wears R, Sutcliffe K. New York, NY: Oxford University Press; 201…
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psnet.ahrq.gov/issue/organisational-safety-indicators-some-conceptual-considerations-and-supplementary-qualitative
August 03, 2016 - Commentary
Organisational safety indicators: some conceptual considerations and a supplementary qualitative approach.
Citation Text:
Kongsvik T, Almklov P, Fenstad J. Organisational safety indicators: Some conceptual considerations and a supplementary qualitative approach. Saf Sci. 20…
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psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
May 30, 2014 - Commentary
The competent surgeon: individual accountability in the era of "systems" failure.
Citation Text:
Whittemore A. The competent surgeon: individual accountability in the era of "systems" failure. Ann Surg. 2009;250(3):357-62. doi:10.1097/SLA.0b013e3181b28c93.
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psnet.ahrq.gov/issue/fda-advise-err-medication-errors-associated-cerebyx
May 02, 2018 - Newspaper/Magazine Article
FDA Advise-ERR: medication errors associated with Cerebyx.
Citation Text:
FDA Advise-ERR: medication errors associated with Cerebyx. ISMP Medication Safety Alert! Acute Care Edition. April 10, 2008;13:1-2.
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psnet.ahrq.gov/issue/rebecca-omalley-report
June 14, 2017 - Book/Report
The Rebecca O'Malley Report.
Citation Text:
The Rebecca O'Malley Report. Cork, Ireland: Health Information and Quality Authority; March 21, 2008.
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psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations
October 28, 2020 - Book/Report
A Thematic Analysis of HSIB's First 22 Investigations.
Citation Text:
A Thematic Analysis of HSIB's First 22 Investigations. Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.
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psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-services-helping-identify-and-reduce-high-risk
September 29, 2021 - Book/Report
Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.
Citation Text:
Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hos…
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psnet.ahrq.gov/issue/building-culture-candour-review-threshold-duty-candour-and-incentives-care-organisations-be
June 12, 2019 - Book/Report
Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.
Citation Text:
Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisa…
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psnet.ahrq.gov/issue/all-her-head-truth-and-lies-early-medicine-taught-us-about-womens-bodies-and-why-it-matters
March 06, 2024 - Book/Report
All in Her Head. The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today.
Citation Text:
All in Her Head. The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today. New York, NY: Harper Wave; 2024. ISBN: 978006…
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psnet.ahrq.gov/issue/factors-affecting-delivery-safe-care-midwifery-units
November 11, 2020 - Book/Report
Factors Affecting the Delivery of Safe Care in Midwifery Units.
Citation Text:
Factors Affecting the Delivery of Safe Care in Midwifery Units. Maternity and Newborn Safety Investigations Programme. Newcastle Upon Tyne, UK: Care Quality Commission; May 2024.
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psnet.ahrq.gov/issue/impact-artificial-intelligence-ai-safety-patients
May 29, 2024 - Webinar
The Impact of Artificial Intelligence (AI) on the Safety of Patients.
Citation Text:
Institute for Healthcare Improvement. The Impact of Artificial Intelligence (AI) on the Safety of Patients. .
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psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-community-languages
May 17, 2023 - Book/Report
Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.
Citation Text:
Clinical Investigation Booking Systems Failures: Written Communications in Community Languages. Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
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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.