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psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
September 29, 2017 - Book/Report
Patient Safety in Ambulatory Settings: Technical Brief.
Citation Text:
Patient Safety in Ambulatory Settings: Technical Brief. Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016.
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psnet.ahrq.gov/issue/mistake-proofing-design-health-care-processes
December 18, 2008 - Book/Report
Mistake-Proofing the Design of Health Care Processes.
Citation Text:
Mistake-Proofing the Design of Health Care Processes. Grout JR. Rockville, MD: Agency for Healthcare Research and Quality; May 2007. AHRQ Publication No. 07-0020.
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psnet.ahrq.gov/issue/error-prone-conditions-lead-student-nurse-related-errors
October 31, 2012 - Newspaper/Magazine Article
Error-prone conditions that lead to student nurse-related errors.
Citation Text:
Error-prone conditions that lead to student nurse-related errors. ISMP Medication Safety Alert! Acute care edition. October 18, 2007.
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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/management-drug-shortages-perioperative-setting
August 13, 2008 - Newspaper/Magazine Article
Management of drug shortages in the perioperative setting.
Citation Text:
Management of drug shortages in the perioperative setting. Murray C, Rycek W, Johnson D, Sifuentes-Tovar F. Pharm Purch Prod. January 2013;10:12.
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psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-term-remedies
May 07, 2018 - Newspaper/Magazine Article
Reporting and second-order problem solving can turn short-term fixes into long-term remedies.
Citation Text:
Reporting and second-order problem solving can turn short-term fixes into long-term remedies. ISMP Medication Safety Alert! Acute Care Edition. May 19, …
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psnet.ahrq.gov/issue/scanning-out-medication-errors-ohio-valley-hospitals-automated-iv-system-provides-real-time
December 21, 2016 - Newspaper/Magazine Article
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.
Citation Text:
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data. Carbas…
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psnet.ahrq.gov/issue/drug-shortages-threaten-patient-safety
May 07, 2018 - Newspaper/Magazine Article
Drug shortages threaten patient safety.
Citation Text:
Drug shortages threaten patient safety. ISMP Medication Safety Alert! Acute Care Edition. July 29, 2010;15:1-4.
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psnet.ahrq.gov/issue/towards-safe-conversational-agents-healthcare
July 10, 2024 - Review
Towards safe conversational agents in healthcare.
Citation Text:
Denecke K. Towards Safe Conversational Agents in Healthcare. Stud Health Technol Inform. 2023;302:157-161. doi:10.3233/shti230094.
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psnet.ahrq.gov/issue/improving-patient-safety-human-factors-methods
June 12, 2019 - United States Meeting/Conference
Improving Patient Safety with Human Factors Methods.
Citation Text:
Improving Patient Safety with Human Factors Methods. Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2025.
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psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections
June 10, 2018 - Newspaper/Magazine Article
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.
Citation Text:
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. ISMP Medication Safety Alert! Acute care edition. July 26, 2007.
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psnet.ahrq.gov/issue/hospital-black-boxes-put-surgical-practices-under-microscope
March 29, 2023 - Newspaper/Magazine Article
Hospital ‘black boxes’ put surgical practices under the microscope.
Citation Text:
Hospital ‘black boxes’ put surgical practices under the microscope. Sadick B. Wall Street Journal. March 19, 2023.
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psnet.ahrq.gov/issue/supplementary-advisory-results-pa-psrs-workgroup-pharmacy-computer-system-safety
October 21, 2020 - Government Resource
Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety.
Citation Text:
Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety. Patient Safety Advisory
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psnet.ahrq.gov/issue/wrong-site-orthopedic-operations-extremities-pennsylvania-experience
July 18, 2018 - Newspaper/Magazine Article
Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.
Citation Text:
Wrong-site orthopedic operations on the extremities: the Pennsylvania experience. Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
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psnet.ahrq.gov/issue/team-communication-operating-room
January 28, 2009 - Commentary
Team communication in the operating room.
Citation Text:
Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand. 2005;49(7):898-901.
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psnet.ahrq.gov/issue/over-top-risky-overuse-adc-overrides-removal-drugs-without-order-and-use-non-profiled
May 07, 2014 - Newspaper/Magazine Article
Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.
Citation Text:
Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets. ISMP Medication …
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psnet.ahrq.gov/issue/how-dekalb-medical-fixed-drug-safety-problems-after-fatal-error
October 11, 2017 - Newspaper/Magazine Article
How DeKalb Medical fixed drug safety problems after fatal error.
Citation Text:
How DeKalb Medical fixed drug safety problems after fatal error. Porter S. HealthLeaders Media. April 26, 2018.
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psnet.ahrq.gov/issue/taking-care-myself-guide-when-i-leave-hospital
November 17, 2010 - Tools/Toolkit
Taking Care of Myself: A Guide for When I Leave the Hospital.
Citation Text:
Taking Care of Myself: A Guide for When I Leave the Hospital. Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0059.
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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/sbar-patients
September 12, 2012 - Commentary
SBAR for patients.
Citation Text:
Denham CR. SBAR for Patients. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e2181660c06.
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