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psnet.ahrq.gov/issue/randomized-controlled-evaluation-insulin-pen-storage-policy
January 23, 2017 - December 11, 2024
Adverse drug event detection in pediatric oncology and hematology patients
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - mitigating the impact of potential errors.1,2
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - Is an adverse drug reaction a safety issue that could have been prevented or not? … Reporting adverse drug reactions (ADRs) through Twitter is another example of social media use in regard
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psnet.ahrq.gov/issue/getting-started-communication-and-resolution-program-crp-policy-or-commitment-statement-cr
February 28, 2024 - Tools/Toolkit
Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR.
Citation Text:
Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR. Collaborative for Accountability and Improvement Po…
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psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
March 16, 2016 - Newspaper/Magazine Article
Reducing preventable harm in hospitals.
Citation Text:
Reducing preventable harm in hospitals. Bornstein D. New York Times. January 26, and February 2, 2016.
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psnet.ahrq.gov/issue/preventing-newborn-falls-and-drops
October 10, 2018 - Newspaper/Magazine Article
Preventing newborn falls and drops.
Citation Text:
Preventing newborn falls and drops. Quick Safety. March 27, 2018;(40):1-2.
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - Hospitals
Health Care Providers
Allergy and Immunology
Radiology
Medication Errors/Preventable Adverse … Drug Events
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
October 27, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty.
Citation Text:
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected
Citation Text:
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
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psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder
April 17, 2019 - Commentary
Case report of a medication error: in the eye of the beholder.
Citation Text:
Naunton M, Nor K, Bartholomaeus A, et al. Case report of a medication error. Medicine (Baltimore). 2016;95(28):e4186. doi:10.1097/md.0000000000004186.
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psnet.ahrq.gov/issue/error-avoidance-recommendations-tubing-misconnections-when-using-luer-tip-connectors
November 21, 2018 - Commentary
Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.
Citation Text:
Simmons D, Phillips MS, Grissinger M, et al. Error-avoidance recommendations for tubing misconnections when usi…
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psnet.ahrq.gov/issue/method-identify-pediatric-high-risk-diagnoses-missed-emergency-department
October 26, 2022 - Study
A method to identify pediatric high-risk diagnoses missed in the emergency department.
Citation Text:
Sundberg M, Perron CO, Kimia A, et al. A method to identify pediatric high-risk diagnoses missed in the emergency department. Diagnosis (Berl). 2018;5(2):63-69. doi:10.1515/dx-2018…
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psnet.ahrq.gov/issue/critical-phase-distractions-anaesthesia-and-sterile-cockpit-concept
April 24, 2018 - Study
Critical phase distractions in anaesthesia and the sterile cockpit concept.
Citation Text:
Broom MA, Capek AL, Carachi P, et al. Critical phase distractions in anaesthesia and the sterile cockpit concept. Anaesthesia. 2011;66(3):175-179. doi:10.1111/j.1365-2044.2011.06623.x.
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psnet.ahrq.gov/issue/electronic-prescribing-within-electronic-health-record-reduces-ambulatory-prescribing-errors
March 21, 2017 - Study
Electronic prescribing within an electronic health record reduces ambulatory prescribing errors.
Citation Text:
Dupree E, Anderson R, McEvoy MD, et al. Professionalism: a necessary ingredient in a culture of safety. Jt Comm J Qual Patient Saf. 2011;37(10):447-455.
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psnet.ahrq.gov/issue/improving-safety-intravenous-admixtures-lessons-learned-pentostamr-overdose
January 04, 2017 - Commentary
Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose.
Citation Text:
Just S, Schepers G, Piotrowski MM, et al. Improving the safety of intravenous admixtures: lessons learned from a Pentostam overdose. Jt Comm J Qual Patient Saf. 2006;32(7…
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psnet.ahrq.gov/issue/medication-kit-conundrum-considerations-enhance-safety-and-efficiency
June 07, 2017 - Commentary
The medication kit conundrum: considerations to enhance safety and efficiency.
Citation Text:
Arthur KJ, Fuller J, Dossett HA, et al. The medication kit conundrum: considerations to enhance safety and efficiency. Am J Health Syst Pharm. 2024;Epub Sep 4. doi:10.1093/ajhp/zxae23…
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psnet.ahrq.gov/issue/ethical-considerations-disclosure-when-medical-error-discovered-during-medicolegal-death
December 14, 2016 - Commentary
Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation.
Citation Text:
Wolf DA, Drake SA, Snow FK. Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation. Am J Forensic …