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  1. 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…
  2. psnet.ahrq.gov/issue/rapid-response-systems-0
    April 07, 2010 - Review Rapid response systems. Citation Text: Rapid response systems. Stevens JP. UpToDate. July 18, 2024. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL J…
  3. psnet.ahrq.gov/issue/follow-ismp-guidelines-safeguard-design-and-use-automated-dispensing-cabinets-adcs
    May 07, 2018 - Newspaper/Magazine Article Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs). Citation Text: Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs). ISMP Medication Safety Alert! Acute Care Edition. Febr…
  4. psnet.ahrq.gov/web-mm/surprise-wire
    July 15, 2020 - August 29, 2016 Medication errors and adverse drug events in pediatric inpatients.
  5. psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - Adverse drug events and medication errors in Australia.
  6. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49408/psn-pdf
    July 01, 2003 - Relationship between medication errors and adverse drug events.
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49851/psn-pdf
    January 01, 2019 - One Bronchoscopy, Two Errors January 1, 2019 Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic respiratory failure…
  9. psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
    March 22, 2009 - The Role of Health Literacy in Patient Safety Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH | March 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety…
  10. psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
    December 22, 2020 - October 7, 2020 Medication safety: reducing anesthesia medication errors and adversedrug events in dentistry part I and II.
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49604/psn-pdf
    June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…
  13. psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…
  14. psnet.ahrq.gov/web-mm/miscalculated-risk
    March 01, 2015 - Miscalculated Risk Citation Text: Strassels SA. Miscalculated Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
  15. psnet.ahrq.gov/issue/never-events-uk-general-practice-survey-views-general-practitioners-their-frequency-and
    June 30, 2021 - Study Never events in UK general practice: A survey of the views of general practitioners on their frequency and acceptability as a safety improvement approach Citation Text: Stocks SJ, Alam R, Bowie P, et al. Never Events in UK General Practice: A Survey of the Views of General Practiti…
  16. psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
    February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! Citation Text: Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
  17. psnet.ahrq.gov/issue/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular-blocker
    June 19, 2019 - Newspaper/Magazine Article Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. Citation Text: Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. ISMP Medication Safety Alert! Acute Ca…
  18. psnet.ahrq.gov/issue/burnout-pediatric-residents-three-years-national-survey
    November 16, 2022 - November 12, 2014 Field test results of a new ambulatory care Medication Error and AdverseDrug Event Reporting System—MEADERS.
  19. psnet.ahrq.gov/issue/effort-improve-electronic-health-record-medication-list-accuracy-between-visits-patients-and
    May 15, 2024 - January 23, 2009 Medication, allergy, and adverse drug event discrepancies in ambulatory
  20. psnet.ahrq.gov/issue/patient-safety-critical-care-environment
    November 16, 2022 - October 26, 2022 Adverse drug event detection in pediatric oncology and hematology patients

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