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  1. Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. | PSNet

    psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea-involuntary-manslaughter
    May 07, 2018 - Newspaper/Magazine Article Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. Citation Text: Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. ISMP Medication Safety Alert! Ac…

  2. Beware of basal opioid infusions with PCA therapy. | PSNet

    psnet.ahrq.gov/issue/beware-basal-opioid-infusions-pca-therapy
    June 05, 2018 - Newspaper/Magazine Article Beware of basal opioid infusions with PCA therapy. Citation Text: Beware of basal opioid infusions with PCA therapy. ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3. Copy Citation Save Save to your library P…

  3. Using Six Sigma to improve patient safety in the perioperative process. | PSNet

    psnet.ahrq.gov/issue/using-six-sigma-improve-patient-safety-perioperative-process
    June 27, 2018 - Newspaper/Magazine Article Using Six Sigma to improve patient safety in the perioperative process. Citation Text: Using Six Sigma to improve patient safety in the perioperative process. Galli BJ, Riebling N, Paraso C, Lehmann G, Yule M. Patient Saf Qual Healthc. July/August 2013;10:36-41…

  4. Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals. | PSNet

    psnet.ahrq.gov/issue/strategically-advancing-patient-and-family-advisory-councils-new-york-state-hospitals
    February 22, 2017 - Book/Report Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals. Citation Text: Strategically Advancing Patient and Family Advisory Councils in New York State Hospitals. Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018. Copy …

  5. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. | PSNet

    psnet.ahrq.gov/issue/handoff-checklists-improve-reliability-patient-handoffs-operating-room-and-postanesthesia
    December 29, 2014 - Study Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Citation Text: Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaes…

  6. Measuring Patient Safety | PSNet

    psnet.ahrq.gov/perspective/measuring-patient-safety
    December 14, 2022 - overall measurement strategy, we have the Meaningful Measures framework  to identify the important topics … 16, 2022 Annual Perspective Annual Perspective: Topics

  7. Age-related COVID-19 vaccine mix-ups. | PSNet

    psnet.ahrq.gov/issue/age-related-covid-19-vaccine-mix-ups
    June 13, 2018 - Press Release/Announcement Age-related COVID-19 vaccine mix-ups. Citation Text: Age-related COVID-19 vaccine mix-ups. National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.  Cop…

  8. Medical Problem Solving: An Analysis of Clinical Reasoning. | PSNet

    psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning
    July 18, 2018 - Book/Report Classic Medical Problem Solving: An Analysis of Clinical Reasoning. Citation Text: Medical Problem Solving: An Analysis of Clinical Reasoning. Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250. Copy Citation …

  9. Health care professionals as second victims after adverse events: a systematic review. | PSNet

    psnet.ahrq.gov/issue/health-care-professionals-second-victims-after-adverse-events-systematic-review
    September 19, 2016 - Review Health care professionals as second victims after adverse events: a systematic review. Citation Text: Seys D, Wu AW, Gerven EV, et al. Health Care Professionals as Second Victims after Adverse Events. Eval Health Prof. 2012;36(2). doi:10.1177/0163278712458918. Copy Citation …

  10. Carers' medication administration errors in the domiciliary setting: a systematic review. | PSNet

    psnet.ahrq.gov/issue/carers-medication-administration-errors-domiciliary-setting-systematic-review
    December 18, 2017 - Review Carers' medication administration errors in the domiciliary setting: a systematic review. Citation Text: Parand A, Garfield S, Vincent CA, et al. Carers' Medication Administration Errors in the Domiciliary Setting: A Systematic Review. PLoS One. 2016;11(12):e0167204. doi:10.1371/j…

  11. Posthospital medication discrepancies: prevalence and contributing factors. | PSNet

    psnet.ahrq.gov/issue/posthospital-medication-discrepancies-prevalence-and-contributing-factors
    July 10, 2008 - Study Classic Posthospital medication discrepancies: prevalence and contributing factors. Citation Text: Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-1847. …

  12. Complexity science: the challenge of complexity in health care. | PSNet

    psnet.ahrq.gov/issue/complexity-science-challenge-complexity-health-care
    March 13, 2013 - Commentary Classic Complexity science: the challenge of complexity in health care. Citation Text: Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323(7313):625-628. Copy Citation Format: Google Scho…

  13. Governing the quality and safety of healthcare: a conceptual framework. | PSNet

    psnet.ahrq.gov/issue/governing-quality-and-safety-healthcare-conceptual-framework
    September 03, 2011 - Commentary Governing the quality and safety of healthcare: a conceptual framework. Citation Text: Brown A, Dickinson H, Kelaher M. Governing the quality and safety of healthcare: A conceptual framework. Soc Sci Med. 2018;202:99-107. doi:10.1016/j.socscimed.2018.02.020. Copy Citation …

  14. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/pharmacy-led-medication-reconciliation-programmes-hospital-transitions-systematic-review-and
    April 18, 2018 - Review Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis. Citation Text: Mekonnen AB, McLachlan AJ, Brien J-AE. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis.…

  15. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. | PSNet

    psnet.ahrq.gov/issue/how-when-and-why-bad-apples-spoil-barrel-negative-group-members-and-dysfunctional-groups
    August 08, 2018 - Commentary Classic How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Citation Text: Felps W, Mitchell TR, Byington E. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. …

  16. The Patient Safety Group. | PSNet

    psnet.ahrq.gov/issue/patient-safety-group
    March 27, 2024 - Multi-use Website The Patient Safety Group. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL August 9, 2006 Development of The Patient Safety Group was motivated by the death of…

  17. Childrens' Hospitals' Solutions for Patient Safety. | PSNet

    psnet.ahrq.gov/issue/childrens-hospitals-solutions-patient-safety
    January 09, 2024 - Multi-use Website Childrens' Hospitals' Solutions for Patient Safety. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 30, 2015 This Web site provides resources related to a …

  18. Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. | PSNet

    psnet.ahrq.gov/issue/do-hospitals-support-second-victims-collective-insights-patient-safety-leaders-maryland
    May 11, 2016 - Study Do hospitals support second victims? Collective insights from patient safety leaders in Maryland. Citation Text: Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. do…

  19. Becoming Hand Hygiene Heroes: implementation of an infection prevention and control campaign for patient and family hospital safety. | PSNet

    psnet.ahrq.gov/issue/becoming-hand-hygiene-heroes-implementation-infection-prevention-and-control-campaign-patient
    June 15, 2016 - Study Becoming Hand Hygiene Heroes: implementation of an infection prevention and control campaign for patient and family hospital safety. Citation Text: Cheng B, Chan M, Abi-Farrage D, et al. Becoming hand hygiene heroes: implementation of an infection prevention and control campaign fo…

  20. Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety. | PSNet

    psnet.ahrq.gov/issue/advance-care-planning-documentation-practices-and-accessibility-electronic-health-record
    December 05, 2012 - Study Emerging Classic Advance care planning documentation practices and accessibility in the electronic health record: implications for patient safety. Citation Text: Walker E, McMahan R, Barnes D, et al. Advance Care Planning Documentation Practices and Access…
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