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psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
December 27, 2018 - Newspaper/Magazine Article
A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!
Citation Text:
A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019
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psnet.ahrq.gov/issue/if-safety-your-yardstick-measuring-culture-top-down-must-be-priority
April 29, 2018 - Newspaper/Magazine Article
If safety is your yardstick, measuring culture from the top down must be a priority.
Citation Text:
If safety is your yardstick, measuring culture from the top down must be a priority. ISMP Medication Safety Alert! Acute care edition. March 22, 2007.
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psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
November 13, 2019 - Book/Report
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.
Citation Text:
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. Farnborough, UK; Healthcare…
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psnet.ahrq.gov/issue/how-dekalb-medical-fixed-drug-safety-problems-after-fatal-error
October 11, 2017 - Newspaper/Magazine Article
How DeKalb Medical fixed drug safety problems after fatal error.
Citation Text:
How DeKalb Medical fixed drug safety problems after fatal error. Porter S. HealthLeaders Media. April 26, 2018.
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psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols-both-handwritten-and-computer-generated-information
May 07, 2018 - Newspaper/Magazine Article
Misidentification of alphanumeric symbols in both handwritten and computer-generated information.
Citation Text:
Misidentification of alphanumeric symbols in both handwritten and computer-generated information. ISMP Medication Safety Alert! Acute Care Edition. …
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psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors
November 01, 2023 - Newspaper/Magazine Article
Unreadable barcodes and multiple barcodes on packages can lead to errors.
Citation Text:
Unreadable barcodes and multiple barcodes on packages can lead to errors. ISMP Medication Safety Alert! Acute care edition. October 19, 2017;22:1-3.
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psnet.ahrq.gov/issue/patient-safety-nursing-practice-0
June 23, 2009 - Commentary
Patient safety in nursing practice.
Citation Text:
Farquhar M, Sharp BAC, Clancy CM. Patient safety in nursing practice. AORN J. 2007;86(3):455-7.
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psnet.ahrq.gov/issue/cognitive-bias-clinical-practice-nurturing-healthy-skepticism-among-medical-students
August 07, 2024 - Commentary
Cognitive bias in clinical practice—nurturing healthy skepticism among medical students.
Citation Text:
Bhatti A. Cognitive bias in clinical practice - nurturing healthy skepticism among medical students. Adv Med Educ Pract. 2018;9:235-237. doi:10.2147/AMEP.S149558.
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psnet.ahrq.gov/issue/patient-safety-tools-primary-care
May 17, 2023 - Commentary
Patient safety tools for primary care.
Citation Text:
Patient safety tools for primary care. Domdera J. Fam Pract Manag. 2023;30(2):24-28.
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psnet.ahrq.gov/issue/ahrq-quality-and-safety-initiatives
May 20, 2009 - Commentary
AHRQ quality and safety initiatives.
Citation Text:
Clancy CM. AHRQ quality and safety initiatives. Jt Comm J Qual Patient Saf. 2005;31(6):354-6.
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psnet.ahrq.gov/issue/battling-hospital-acquired-infections
June 27, 2018 - Audiovisual
Battling hospital-acquired infections.
Citation Text:
Battling hospital-acquired infections. Gross T; Shannon R. NPR. January 9, 2008.
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psnet.ahrq.gov/issue/kaiser-permanentes-innovation-front-lines
January 20, 2021 - Commentary
Kaiser Permanente's innovation on the front lines.
Citation Text:
McCreary L. Kaiser Permanente's innovation on the front lines. Harv Bus Rev. 2010;88(9):92, 94-7, 126.
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psnet.ahrq.gov/issue/implementing-patient-safety-alert-system
June 21, 2015 - Study
Implementing a patient safety alert system.
Citation Text:
Furman C. Implementing a patient safety alert system. Nurs Econ. 2005;23(1):42-5.
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Downloa…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/node/33727/psn-pdf
March 01, 2012 - Can Research Help Us Improve the Medical Liability
System?
March 1, 2012
Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
Perspective
The United States medical malpractice liabili…
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…