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psnet.ahrq.gov/issue/improving-healthcare-team-communication-building-lessons-aviation-and-aerospace
August 08, 2007 - Book/Report
Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace.
Citation Text:
Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. Nemeth CP, ed. Burlington, VT: Ashgate Publishing; 2008. ISBN: 9780754670254.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-44
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Neuromuscular Blocker Mix-up in the Pharmacy; ISMP and Doctor's Digest Launch New iPhone Application; “UD” for “Ut Dictum”—an Ambiguous and Dangerous Abbreviation; Order by Metric Weight, Not Volume.…
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psnet.ahrq.gov/issue/community-pharmacy-survey-patient-safety-culture
October 23, 2019 - Measurement Tool/Indicator
Community Pharmacy Survey on Patient Safety Culture.
Citation Text:
Community Pharmacy Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; July 2018.
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psnet.ahrq.gov/issue/fda-advise-err-prevent-dangerous-drug-device-interaction-causing-falsely-elevated-glucose
May 02, 2018 - Newspaper/Magazine Article
FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.
Citation Text:
FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels. ISMP Medication Safety Alert! Acute Care Edition…
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psnet.ahrq.gov/issue/francis-report-one-year
April 02, 2014 - Book/Report
The Francis Report: One Year On.
Citation Text:
The Francis Report: One Year On. Thorlby R, Smith J, Williams S, Dayan M. London, UK: Nuffield Trust; February 2014.
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psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-and-recommendations-independent-review-maternity-services
April 27, 2022 - Book/Report
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.
Citation Text:
Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at …
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psnet.ahrq.gov/issue/nurses-role-communication-and-patient-safety
July 23, 2008 - Commentary
Nurses' role in communication and patient safety.
Citation Text:
Nadzam DM. Nurses' role in communication and patient safety. J Nurs Care Qual. 2009;24(3):184-188. doi:10.1097/01.NCQ.0000356905.87452.62.
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psnet.ahrq.gov/issue/she-was-headed-locked-psych-ward-then-er-doctor-made-startling-discovery
March 03, 2021 - Newspaper/Magazine Article
She was headed to a locked psych ward. Then an ER doctor made a startling discovery.
Citation Text:
She was headed to a locked psych ward. Then an ER doctor made a startling discovery. Boodman SG. Washington Post. February 12, 2022.
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psnet.ahrq.gov/issue/oxford-professional-practice-handbook-patient-safety
June 16, 2012 - Book/Report
Oxford Professional Practice: Handbook of Patient Safety.
Citation Text:
Oxford Professional Practice: Handbook of Patient Safety. Lachman P, Runnacles J, Jayadev A et al, eds. London, England; Oxford University Press; 2022. ISBN: 9780192846877.
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psnet.ahrq.gov/issue/smart-pump-custom-concentrations-without-hard-low-concentration-alerts
June 10, 2018 - Newspaper/Magazine Article
Smart pump custom concentrations without hard "low concentration" alerts.
Citation Text:
Smart pump custom concentrations without hard "low concentration" alerts. ISMP Medication Safety Alert! Acute care edition. February 23, 2012;17:1,3-4.
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psnet.ahrq.gov/issue/adverse-health-care-events-reporting-system-what-have-we-learned
February 28, 2015 - Book/Report
Adverse Health Care Events Reporting System: What Have We Learned?
Citation Text:
Adverse Health Care Events Reporting System: What Have We Learned? St. Paul, MN: Minnesota Department of Health; January 2009.
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psnet.ahrq.gov/issue/wrong-site-surgery
March 13, 2013 - Commentary
Wrong site surgery.
Citation Text:
Fraser SG, Adams W. Wrong site surgery. Br J Ophthalmol. 2006;90(7):814-6.
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psnet.ahrq.gov/issue/4-skin-conditions-doctors-often-misdiagnose
September 30, 2020 - Newspaper/Magazine Article
4 skin conditions doctors often misdiagnose.
Citation Text:
4 skin conditions doctors often misdiagnose. Oglethorpe A. Women's Health. November 4, 2020.
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psnet.ahrq.gov/issue/10-derm-mistakes-you-dont-want-make
March 26, 2008 - Commentary
10 derm mistakes you don't want to make.
Citation Text:
Fox GN. 10 derm mistakes you don't want to make. J Fam Pract. 2008;57(3):162-9.
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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/crushing-or-splitting-medications-unrecognized-hazards
October 26, 2010 - Commentary
Crushing or splitting medications: unrecognized hazards.
Citation Text:
Gill D, Spain M, Edlund BJ. Crushing or Splitting Medications: Unrecognized Hazards. J Gerontol Nurs. 2012. doi:10.3928/00989134-20111213-01.
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psnet.ahrq.gov/issue/how-psos-help-health-care-organizations-improve-patient-safety-culture
May 25, 2016 - Book/Report
How PSOs Help Health Care Organizations Improve Patient Safety Culture.
Citation Text:
How PSOs Help Health Care Organizations Improve Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; April 2016. AHRQ Pub. No. 16-0026-EF.
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psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture
December 24, 2008 - Measurement Tool/Indicator
Medical Office Survey on Patient Safety Culture.
Citation Text:
Medical Office Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; June 2023.
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psnet.ahrq.gov/issue/safety-medication-use
January 01, 2019 - Book/Report
Safety in Medication Use.
Citation Text:
Safety in Medication Use. Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-42
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Oral Syringes: A Crucial and Economical Risk-Reduction Strategy that has Not Been Fully Utilized; Caution regarding Once-Weekly Levothyroxine; When Drug Strengths Differ by 10-Fold; Lower Colchicine Do…