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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/medical-error-and-moral-luck
October 02, 2024 - Commentary
Medical error and moral luck.
Citation Text:
Allhoff F. Medical Error and Moral Luck. Kennedy Inst Ethics J. 2019;29(3):187-203. doi:10.1353/ken.2019.0022.
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psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols
March 26, 2014 - Newspaper/Magazine Article
Misidentification of alphanumeric symbols.
Citation Text:
Misidentification of alphanumeric symbols. ISMP Medication Safety Alert! Acute care edition. June 5, 2014;19:1-2,4-5.
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psnet.ahrq.gov/issue/inattentional-blindness-what-captures-your-attention-0
November 24, 2021 - Commentary
'Inattentional blindness': what captures your attention?
Citation Text:
Grissinger M. 'Inattentional blindness': what captures your attention? P.T. 2012;37(10):542-555.
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psnet.ahrq.gov/issue/diagnostic-safety-issue-briefs
December 24, 2008 - Special or Theme Issue
Diagnostic Safety Issue Briefs.
Citation Text:
Diagnostic Safety Issue Briefs. Rockville, MD: Agency for Healthcare Research and Quality; 2020-2024.
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psnet.ahrq.gov/issue/ismps-list-high-alert-medications-acute-care-settings
April 17, 2024 - Fact Sheet/FAQs
ISMP's List of High-Alert Medications in Acute Care Settings.
Citation Text:
ISMP's List of High-Alert Medications in Acute Care Settings. Horsham, PA; Institute for Safe Medication Practices: 2024.
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psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
May 11, 2017 - Organizational Policy/Guidelines
ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults.
Citation Text:
ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. Horsham, PA: Institute for Safe Medication Practices; May 2017.
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psnet.ahrq.gov/issue/targeted-medication-safety-best-practices-hospitals
January 26, 2023 - Organizational Policy/Guidelines
Targeted Medication Safety Best Practices for Hospitals.
Citation Text:
Targeted Medication Safety Best Practices for Hospitals. Plymouth Meeting, PA: Institute for Safe Medication Practices; 2024.
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psnet.ahrq.gov/issue/partnering-patients-drive-shared-decisions-better-value-and-care-improvement-workshop
September 23, 2015 - Meeting/Conference Proceedings
Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings.
Citation Text:
Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings. Roundtable on Value and …
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psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries
August 06, 2016 - Book/Report
Classic
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries.
Citation Text:
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023.
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psnet.ahrq.gov/issue/study-clinicians-copy-and-paste-about-half-text-ehr-progress-notes
July 13, 2022 - Newspaper/Magazine Article
Study: clinicians copy and paste about half of text in EHR progress notes.
Citation Text:
Study: clinicians copy and paste about half of text in EHR progress notes. Landi H. Healthcare Innovation. October 2, 2017.
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psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
December 23, 2016 - Sentinel Event Alerts
Managing the risks of direct oral anticoagulants.
Citation Text:
Managing the risks of direct oral anticoagulants. Sentinel Event Alert. July 30, 2019;(61):1-5.
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psnet.ahrq.gov/issue/pharmacy-mixes-prescriptions
March 10, 2021 - Commentary
Pharmacy mixes up prescriptions.
Citation Text:
Brushwood DB. Pharmacy error leads to fatal medication mix-up. Pharmacy Today. 2017;23(12):42. doi:10.1016/j.ptdy.2017.11.012.
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psnet.ahrq.gov/issue/science-simulation-healthcare-defining-and-developing-clinical-expertise
November 02, 2011 - Meeting/Conference Proceedings
The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise.
Citation Text:
The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise. Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.
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psnet.ahrq.gov/issue/oral-solid-medication-appearance-should-play-greater-role-medication-error-prevention
February 20, 2019 - Newspaper/Magazine Article
Oral solid medication appearance should play a greater role in medication error prevention.
Citation Text:
Oral solid medication appearance should play a greater role in medication error prevention. ISMP Medication Safety Alert! Acute care edition. July 28, 201…
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psnet.ahrq.gov/issue/structured-patient-handoffs-movement-toward-adverse-event-reduction-perioperative-unit
December 16, 2020 - Newspaper/Magazine Article
Structured patient handoffs: the movement toward adverse event reduction in the perioperative unit.
Citation Text:
Structured patient handoffs: the movement toward adverse event reduction in the perioperative unit. Hamilton WL.
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psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
November 21, 2018 - Newspaper/Magazine Article
I-PASS checklist: a powerful tool for patient handoffs.
Citation Text:
I-PASS checklist: a powerful tool for patient handoffs. Peeples L. Pharmacy Practice News. October 10, 2018.
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psnet.ahrq.gov/issue/medication-errors-outpatient-pediatrics
December 07, 2022 - Commentary
Medication errors in outpatient pediatrics.
Citation Text:
Berrier K. Medication Errors in Outpatient Pediatrics. MCN Am J Matern Child Nurs. 2016;41(5):280-6. doi:10.1097/NMC.0000000000000261.
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psnet.ahrq.gov/issue/building-high-reliability-organization-one-systems-patient-safety-journey
November 23, 2005 - Commentary
Building a high-reliability organization: one system's patient safety journey.
Citation Text:
Building a high-reliability organization: one system's patient safety journey. J Healthc Manag. 2017;62.
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psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-surgical-care-safety
November 30, 2016 - Book/Report
Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety.
Citation Text:
Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. Wiley K, Davies JM. Edmonton, AB: Canadia…