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psnet.ahrq.gov/issue/pain-management-and-opioid-epidemic-balancing-societal-and-individual-benefits-and-risks
March 29, 2006 - Book/Report
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.
Citation Text:
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Bonnie RJ, Ford M…
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psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
March 10, 2021 - Newspaper/Magazine Article
Prevent errors during emergency use of hypertonic sodium chloride solutions.
Citation Text:
Prevent errors during emergency use of hypertonic sodium chloride solutions. ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
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psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
July 05, 2008 - Meeting/Conference Proceedings
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Citation Text:
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…
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psnet.ahrq.gov/issue/npsd-data-spotlight-patient-safety-and-covid-19-qualitative-analysis-concerns-during-public
February 15, 2023 - Book/Report
NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021.
Citation Text:
NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021. Rockvil…
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psnet.ahrq.gov/issue/professionalism-lapses-and-adverse-childhood-experiences-reflections-island-last-resort
October 14, 2015 - Commentary
Professionalism lapses and adverse childhood experiences: reflections from the island of last resort.
Citation Text:
Williams BW. Professionalism Lapses and Adverse Childhood Experiences: Reflections From the Island of Last Resort. Acad Med. 2019;94(8):1081-1083. doi:10.1097/A…
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psnet.ahrq.gov/issue/girl-who-died-twice-every-patients-nightmare-libby-zion-case-and-hidden-hazards-hospitals
May 09, 2018 - Book/Report
Classic
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.
Citation Text:
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. Robins NS…
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psnet.ahrq.gov/issue/iv-push-medications-survey-results-part-1-and-part-2
December 12, 2018 - Newspaper/Magazine Article
IV push medications survey results—part 1 and part 2.
Citation Text:
IV push medications survey results—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
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psnet.ahrq.gov/issue/pharmacist-medication-assessments-surgical-preadmission-clinic
October 15, 2008 - Study
Pharmacist medication assessments in a surgical preadmission clinic.
Citation Text:
Kwan Y, Fernandes O, Nagge JJ, et al. Pharmacist medication assessments in a surgical preadmission clinic. Arch Intern Med. 2007;167(10):1034-40.
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psnet.ahrq.gov/issue/learning-how-learn-compliance-patient-safety-alerts-nhs
September 01, 2021 - Government Resource
Learning how to learn: compliance with patient safety alerts in the NHS.
Citation Text:
Learning how to learn: compliance with patient safety alerts in the NHS. Donaldson L. Chapter in: On the State of Public Health: Annual Report of the Chief Medical Officer. L…
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psnet.ahrq.gov/issue/limits-checklists-handoff-and-narrative-thinking
July 01, 2017 - Commentary
The limits of checklists: handoff and narrative thinking.
Citation Text:
Hilligoss B, Moffatt-Bruce SD. The limits of checklists: handoff and narrative thinking. BMJ Qual Saf. 2014;23(7):528-33. doi:10.1136/bmjqs-2013-002705.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Over the next 10 minutes, the child’s cardiovascular status deteriorated, requiring epinephrine.
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - This is because the Universal Protocol does not differentiate between types of cases requiring imaging … For example, a change in hospital policy requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - For patients requiring intermittent paracentesis for symptom relief, it would also be important to ensure … they are taking diuretic therapy or not requiring an increase in that therapy.
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - are also known as critical values, or more accurately as "alert" values,
since some reflect errors requiring … immediate correction rather than clinical conditions requiring immediate
treatment.
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - However, he rapidly
experienced further respiratory decompensation requiring intubation and mechanical … ventilation, as well as
hemodynamic compromise requiring vasopressor support.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - hospital course was marked by multiorgan failure, septic shock, and spontaneous bowel
perforation requiring … antibiotics are warranted, rather than relying on evidence-based
criteria), and health care system factors (requiring
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - an interruption.(13) Consequently, inadequate laboratory test result follow-up is a system problem
requiring … Inadequate laboratory test result follow-up is a system problem requiring a system solution.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - potential for medical errors.( 12 ) In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented with the use of a standardized checklist requiring
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - beta-glucuronidase in the newborn intestine and, now lipid soluble again, is reabsorbed into the portal circulation, requiring … isoimmunization, maternal antibody can persist for months, and can continue to cause hemolysis, sometimes requiring