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psnet.ahrq.gov/issue/administering-just-diluent-or-one-two-vaccine-components-leaves-patients-unprotected
May 07, 2018 - Newspaper/Magazine Article
Administering just the diluent or one of two vaccine components leaves patients unprotected.
Citation Text:
Administering just the diluent or one of two vaccine components leaves patients unprotected. ISMP Medication Safety Alert! Acute care edition. May 22, 20…
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psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
April 20, 2022 - Webinar
Diversion is a Threat to Patient Safety: Adopting Best Practices.
Citation Text:
Diversion is a Threat to Patient Safety: Adopting Best Practices. Institute for Safe Medication Practices. April 6, 2022.
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psnet.ahrq.gov/issue/technological-methods-used-prevent-errors-arent-infallible
January 05, 2017 - Newspaper/Magazine Article
Technological methods used to prevent errors aren't infallible.
Citation Text:
Santell JP. Technological methods used to prevent errors aren't infallible. Mater Manag Health Care. 2006;15(12):26-30.
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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/challenges-requiring-five-characters-during-adc-drug-searches-override
October 20, 2021 - Newspaper/Magazine Article
Challenges with requiring five characters during ADC drug searches via override.
Citation Text:
Challenges with requiring five characters during ADC drug searches via override. ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3.
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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/clinical-reminder-about-safe-use-insulin-vials
June 10, 2018 - Newspaper/Magazine Article
A clinical reminder about the safe use of insulin vials.
Citation Text:
A clinical reminder about the safe use of insulin vials. ISMP Medication Safety Alert! Acute care edition. February 21, 2013;18:1-3.
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psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-anesthesia
July 25, 2018 - Organizational Policy/Guidelines
APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.
Citation Text:
APSF endorsed statement on revising recommendations for patient monitoring during anesthesia. The APSF Committee on Technology. APSF Newsletter.&n…
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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/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/durasal-durezol-mix-illustrates-how-dangerous-product-problems-persist-long-after-recognition
June 10, 2018 - Newspaper/Magazine Article
Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.
Citation Text:
Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition. ISMP Medication Safety Alert! Acute care edition. …
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psnet.ahrq.gov/issue/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry-errors
June 10, 2018 - Newspaper/Magazine Article
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.
Citation Text:
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. ISMP Medication Safety Alert! Acute care…
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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 …
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psnet.ahrq.gov/issue/side-tracks-safety-express-interruptions-lead-errors-and-unfinishedwait-what-was-i-doing
June 10, 2018 - Newspaper/Magazine Article
Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?
Citation Text:
Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? ISMP Medication Safety Alert! Acute care…
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psnet.ahrq.gov/issue/shortage-everything-except-errors-harm-associated-drug-shortages
February 13, 2019 - Newspaper/Magazine Article
A shortage of everything except errors: harm associated with drug shortages.
Citation Text:
A shortage of everything except errors: harm associated with drug shortages. ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3.
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psnet.ahrq.gov/issue/improving-patient-safety-office-institute-safety-office-based-surgery
August 13, 2014 - Newspaper/Magazine Article
Improving patient safety in the office: The Institute for Safety in Office-Based Surgery.
Citation Text:
Improving patient safety in the office: The Institute for Safety in Office-Based Surgery. Urman RD, Shapiro FE. APSF Newsletter. 2011;3-4,9.
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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/human-factors-and-ergonomics-healthcare
September 15, 2021 - Special or Theme Issue
Human Factors and Ergonomics in Healthcare.
Citation Text:
Human Factors and Ergonomics in Healthcare. Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.
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psnet.ahrq.gov/issue/risk-management-obstetrics-and-gynaecology
June 15, 2011 - Special or Theme Issue
Risk Management in Obstetrics and Gynaecology.
Citation Text:
Risk Management in Obstetrics and Gynaecology. Edozien LC, ed. Best Pract Res Clin Obstet Gynaecol. 2013;27:A1-A14,479-640.
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psnet.ahrq.gov/issue/efforts-improve-safety-culture-elderly-nursing-homes-qualitative-study
April 18, 2018 - Study
Efforts to improve the safety culture of the elderly in nursing homes: a qualitative study.
Citation Text:
Indarwati R, Efendi F, Fauziningtyas R, et al. Efforts to improve the safety culture of the elderly in nursing homes: a qualitative study. Risk Manag Healthc Policy. 2023;16:3…