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  1. Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. | PSNet

    psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals
    June 16, 2019 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 9, 2010 ISMP medication error report analysis.

  2. Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention. | PSNet

    psnet.ahrq.gov/issue/labeling-morphine-milligram-equivalents-opioid-packaging-potential-patient-safety
    March 06, 2019 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  3. Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation. | PSNet

    psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error-prevention-intravenous
    December 22, 2021 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  4. John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic. | PSNet

    psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-safety-effectiveness-and-efficiency-web-based-virtual
    September 13, 2023 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  5. Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS. | PSNet

    psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-infusion-pump-safety-ders
    March 22, 2023 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837136/psn-pdf
    May 18, 2022 - What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency … department: an analysis of serious adverse event reports. … What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency … department: an analysis of serious adverse event reports. … https://psnet.ahrq.gov/issue/what-can-we-learn-depth-analysis-human-errors-resulting-diagnostic-errors

  7. Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. | PSNet

    psnet.ahrq.gov/issue/effect-multifaceted-clinical-pharmacist-intervention-medication-safety-after-hospitalization
    April 28, 2021 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  8. Improving insulin distribution and administration safety using Lean Six Sigma methodologies. | PSNet

    psnet.ahrq.gov/issue/improving-insulin-distribution-and-administration-safety-using-lean-six-sigma-methodologies
    March 19, 2019 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849124/psn-pdf
    May 17, 2023 - Human factors and safety analysis methods used in the design and redesign of electronic medication … Human factors and safety analysis methods used in the design and redesign of electronic medication management … https://psnet.ahrq.gov/issue/human-factors-and-safety-analysis-methods-used-design-and-redesign- electronic-medication … Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally … This review identifies human factors and safety analysis methods applied to EMMS.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836744/psn-pdf
    March 17, 2022 - Drug-related deaths among inpatients: a meta-analysis. … Drug-related deaths among inpatients: a meta-analysis. … https://psnet.ahrq.gov/issue/drug-related-deaths-among-inpatients-meta-analysis Adverse drug events … Based on 23 included studies from US and international settings, this meta-analysis estimated that drug-related … https://psnet.ahrq.gov/issue/drug-related-deaths-among-inpatients-meta-analysis https://psnet.ahrq.gov

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850167/psn-pdf
    June 07, 2023 - Perception of feeling safe perioperatively: a concept analysis. … Perception of feeling safe perioperatively: a concept analysis. … https://psnet.ahrq.gov/issue/perception-feeling-safe-perioperatively-concept-analysis Patients expect … This concept analysis describes defining attributes (participation, control, presence) of patients in … https://psnet.ahrq.gov/issue/perception-feeling-safe-perioperatively-concept-analysis https://psnet.ahrq.gov

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74212/psn-pdf
    January 01, 2022 - Using failure mode and effects analysis to increase patient safety in cancer chemotherapy. … Using Failure Mode and Effects Analysis to increase patient safety in cancer chemotherapy. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer- … Using failure mode and effects analysis (FMEA), researchers identified potential failures related to … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer-chemotherapy

  13. Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. | PSNet

    psnet.ahrq.gov/issue/three-new-best-practices-2022-2023-targeted-medication-safety-best-practices-hospitals
    March 15, 2022 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  14. FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only. | PSNet

    psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only
    February 10, 2021 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  15. Listen carefully: the risk of error in spoken medication orders. | PSNet

    psnet.ahrq.gov/issue/listen-carefully-risk-error-spoken-medication-orders
    November 16, 2022 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849331/psn-pdf
    May 24, 2023 - Long-term care healthcare-associated infections in 2022: an analysis of 20,216 reports. … Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports. … https://psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2022-analysis-20216-reports … Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis … https://psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2022-analysis-20216-reports

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851656/psn-pdf
    July 26, 2023 - Investigation of urology intraoperative events leading to root cause analysis at national VA medical … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis- … national-va-medical Root cause analysis (RCA) is one tool commonly used to identify factors contributing … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47096/psn-pdf
    November 14, 2018 - analysis system. … Analysis System. … - cause-analysis This analysis of the Veterans Health Administration root cause analysis database identified … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35721/psn-pdf
    March 28, 2011 - Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric

  20. Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals. | PSNet

    psnet.ahrq.gov/issue/preparing-your-hospital-compliance-joint-commissions-national-patient-safety-goals
    December 30, 2014 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.
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