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  1. Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. | PSNet

    psnet.ahrq.gov/issue/survey-suggests-possible-downward-trend-identifying-key-drugsdrug-classes-high-alert
    July 30, 2014 - Newspaper/Magazine Article Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. Citation Text: Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. ISMP Medication Safety Alert! Acute …

  2. Pump up the volume: how to prioritize events and analyze error data. | PSNet

    psnet.ahrq.gov/issue/pump-volume-how-prioritize-events-and-analyze-error-data
    March 14, 2023 - Newspaper/Magazine Article Pump up the volume: how to prioritize events and analyze error data. Citation Text: Pump up the volume: how to prioritize events and analyze error data. ISMP Medication Safety Alert! Acute care edition. February 9, 2023;28(3):1-4. Copy Citation …

  3. Cancer drug shortages are creating dire circumstances for some patients. | PSNet

    psnet.ahrq.gov/issue/cancer-drug-shortages-are-creating-dire-circumstances-some-patients
    September 21, 2022 - Newspaper/Magazine Article Cancer drug shortages are creating dire circumstances for some patients. Citation Text: Cancer drug shortages are creating dire circumstances for some patients. Lovelace B, Jr, Kopf M. NBC. April 11, 2023. Copy Citation Save Save to yo…

  4. Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. | PSNet

    psnet.ahrq.gov/issue/two-effective-initiatives-c-suite-leaders-improve-medication-safety-and-reliability-outcomes
    March 14, 2023 - Newspaper/Magazine Article Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. Citation Text: Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. ISMP Medication Safety Alert! …

  5. Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. | PSNet

    psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient
    March 14, 2023 - Newspaper/Magazine Article Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. Citation Text: Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. ISMP Medication Safety Alert! Acute care editi…

  6. Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. | PSNet

    psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-causes-vaccine-errors
    June 18, 2014 - Newspaper/Magazine Article Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. Citation Text: Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. ISMP Medication Safety Alert! Acute ca…

  7. The absence of a drug–disease interaction alert leads to a child's death. | PSNet

    psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
    July 08, 2015 - Newspaper/Magazine Article The absence of a drug–disease interaction alert leads to a child's death. Citation Text: The absence of a drug–disease interaction alert leads to a child's death. ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4. Copy Citation …

  8. Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. | PSNet

    psnet.ahrq.gov/issue/still-outside-bulls-eye-2014-2015-targeted-medication-safety-best-practices
    March 15, 2022 - Newspaper/Magazine Article Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. Citation Text: Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. ISMP Medication Safety Alert! Acute care edition. March 27, 2014;19:1-5. Copy …

  9. Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error | PSNet

    psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error
    February 10, 2021 - Newspaper/Magazine Article Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error Citation Text: Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. …

  10. Sensemaking in Organizations. | PSNet

    psnet.ahrq.gov/issue/sensemaking-organizations
    June 20, 2018 - Book/Report Classic Sensemaking in Organizations. Citation Text: Sensemaking in Organizations. Weick KE. Thousand Oaks, CA: Sage Publications; 1995. ISBN: 9780803971776. Copy Citation Save Save to your library Print Download PDF…

  11. Risk, society and system failure. | PSNet

    psnet.ahrq.gov/issue/risk-society-and-system-failure
    November 29, 2023 - Commentary Risk, society and system failure. Citation Text: Scalliet P. Risk, society and system failure. Radiotherapy and Oncology. 2006;80(3). doi:10.1016/j.radonc.2006.07.003. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  12. NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, 2021. | PSNet

    psnet.ahrq.gov/issue/ncicle-pathways-excellence-expectations-optimal-clinical-learning-environment-achieve-safe
    October 18, 2017 - Book/Report NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, 2021. Citation Text: NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quali…

  13. Costs of medical injuries in Utah and Colorado. | PSNet

    psnet.ahrq.gov/issue/costs-medical-injuries-utah-and-colorado
    June 30, 2021 - Study Classic Costs of medical injuries in Utah and Colorado. Citation Text: Costs of medical injuries in Utah and Colorado. Thomas EJ; Studdert DM; Newhouse JP; Zbar BI; Howard KM; Williams EJ; Brennan TA Copy Citation Save Save to your …

  14. Implementing a systematic response to medication errors. | PSNet

    psnet.ahrq.gov/issue/implementing-systematic-response-medication-errors
    August 27, 2009 - Commentary Implementing a systematic response to medication errors. Citation Text: Larsen D, Cole R, Higton P. Implementing a systematic response to medication errors. Nurs Stand. 2007;21(48):35-40. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote…

  15. Medication errors: the year in review. | PSNet

    psnet.ahrq.gov/issue/medication-errors-year-review
    May 02, 2018 - Newspaper/Magazine Article Medication errors: the year in review. Citation Text: Medication errors: the year in review. Valentine D, Ingram V, Fobi B et al. Pharmacy Practice News. September 10, 2019. Copy Citation Save Save to your library Print Down…

  16. "It's not our ass": medical resident sense-making regarding lawsuits. | PSNet

    psnet.ahrq.gov/issue/its-not-our-ass-medical-resident-sense-making-regarding-lawsuits
    December 02, 2015 - Study "It's not our ass": medical resident sense-making regarding lawsuits. Citation Text: Noland CM, Carl WJ. "It's not our ass": medical resident sense-making regarding lawsuits. Health Commun. 2006;20(1):81-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

  17. Surgeon age and operative mortality in the United States. | PSNet

    psnet.ahrq.gov/issue/surgeon-age-and-operative-mortality-united-states
    August 02, 2015 - Study Surgeon age and operative mortality in the United States. Citation Text: Waljee JF, Greenfield LJ, Dimick JB, et al. Surgeon Age and Operative Mortality in the United States. Transactions of the .. Meeting of the American Surgical Association. 2006;124. doi:10.1097/01.sla.0000234…

  18. Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns. | PSNet

    psnet.ahrq.gov/issue/defense-health-agency-processes-responding-provider-quality-and-safety-concerns
    December 09, 2020 - Book/Report Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns. Citation Text: Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns. Washington DC; Governmental Accountability Office; December 1, 2020. Publication GAO-…

  19. Preprinted order sets as a safety intervention in pediatric sedation. | PSNet

    psnet.ahrq.gov/issue/preprinted-order-sets-safety-intervention-pediatric-sedation
    April 16, 2010 - Study Preprinted order sets as a safety intervention in pediatric sedation. Citation Text: Broussard M, Bass PF, Arnold CL, et al. Preprinted order sets as a safety intervention in pediatric sedation. J Pediatr. 2009;154(6):865-8. doi:10.1016/j.jpeds.2008.12.022. Copy Citation Fo…

  20. Errors in diagnosis of spinal epidural abscesses in the era of electronic health records. | PSNet

    psnet.ahrq.gov/issue/errors-diagnosis-spinal-epidural-abscesses-era-electronic-health-records
    April 24, 2018 - Study Errors in diagnosis of spinal epidural abscesses in the era of electronic health records. Citation Text: Bhise V, Meyer AND, Singh H, et al. Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records. Am J Med. 2017;130(8). doi:10.1016/j.amjmed.2017.03…
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