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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.
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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.
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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…
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - August 29, 2016
Medication errors and adverse drug events in pediatric inpatients.
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - Adverse drug events and medication errors in Australia.
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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…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Relationship between medication errors
and adverse drug events.
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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…
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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…
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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 adverse … drug events in dentistry part I and II.
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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…
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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…
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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…
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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.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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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…
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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…
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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…
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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 Adverse … Drug Event Reporting System—MEADERS.
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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
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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