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psnet.ahrq.gov/issue/physicians-perspectives-regarding-prescription-drug-monitoring-program-use-within-department
February 17, 2017 - 2020
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Related Resources
Discrepancies in written versus calculated
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - should be adjusted
Guidelines recommend starting with a total opioid dose that is 25%–50% lower than calculated … If changing to a different opioid, use a dose 25%–50% lower than the calculated equianalgesic dose
Most
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psnet.ahrq.gov/node/46283/psn-pdf
April 24, 2018 - Decreasing prescribing errors during pediatric
emergencies: a randomized simulation trial.
April 24, 2018
Larose G, Levy A, Bailey B, et al. Decreasing Prescribing Errors During Pediatric Emergencies: A
Randomized Simulation Trial. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-3200.
https://psnet.ahrq.gov/issue/d…
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psnet.ahrq.gov/node/38877/psn-pdf
April 08, 2011 - Computerized order entry with limited decision support to
prevent prescription errors in a PICU.
April 8, 2011
Kadmon G, Bron-Harlev E, Nahum E, et al. Computerized order entry with limited decision support to
prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935-940. doi:10.1542/peds.2008-2737.
https…
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - monitoring programs (PDMPs)
Recognize differences in how oral morphine milligram-equivalents (OME) are calculated … Of note, oral morphine milligram-
equivalents (OME) in this case are calculated using the institutions … Opioid A to Opioid B:
Once the conversion is carried out, clinicians may want to reduce the newly calculated
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - Take-Home Points
Calculated AG should be integrated into laboratory reports of metabolic panels, with
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Therefore, the calculated estimated date of delivery (EDD) needs to be modified, taking into consideration … becomes less reliable, and in the second and third trimesters, estimation of gestational age depends on a calculated
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psnet.ahrq.gov/issue/measurement-matters-changing-penalty-calculations-under-hospital-acquired-condition-reduction
August 10, 2022 - Study
Measurement matters: changing penalty calculations under the hospital acquired condition reduction program (HACRP) cost hospitals millions.
Citation Text:
Vsevolozhskaya OA, Manz KC, Zephyr PM, et al. Measurement matters: changing penalty calculations under the hospital acquired co…
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Therefore, the calculated estimated date of delivery
(EDD) needs to be modified, taking into consideration … less reliable, and in the second and third trimesters, estimation of
gestational age depends on a calculated
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - Take-Home Points
Calculated AG should be integrated into laboratory reports of metabolic panels,
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psnet.ahrq.gov/node/73913/psn-pdf
January 01, 2022 - A standardized formulary to reduce pediatric medication
dosing errors: a mixed methods study.
October 6, 2021
Bosson N, Kaji AH, Gausche-Hill M. A standardized formulary to reduce pediatric medication dosing errors:
a mixed methods study. Prehosp Emerg Care. 2022;26(4):492-502. doi:10.1080/10903127.2021.1955058.
h…
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psnet.ahrq.gov/node/41932/psn-pdf
December 19, 2012 - Important change to heparin container labels to clearly
state the total drug strength.
December 19, 2012
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012.
https://psnet.ahrq.gov/issue/important-change-heparin-container-labels-clearly-state-total-drug-strength
This announc…
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psnet.ahrq.gov/node/42290/psn-pdf
May 22, 2013 - Safety in Numbers: Evidence-based Development of a
Medicine Management Learning Tool.
May 22, 2013
Holland K, ed. Nurse Educ Pract. 2013;13(2):e1-e87.
https://psnet.ahrq.gov/issue/safety-numbers-evidence-based-development-medicine-management-
learning-tool
Articles in this special issue outline the developm…
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psnet.ahrq.gov/node/39373/psn-pdf
March 17, 2010 - The impact of electronic medical records data sources on
an adverse drug event quality measure.
March 17, 2010
Kahn MG, Ranade D. The impact of electronic medical records data sources on an adverse drug event
quality measure. J Am Med Inform Assoc. 2010;17(2):185-91. doi:10.1136/jamia.2009.002451.
https://psnet.ah…
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psnet.ahrq.gov/node/39731/psn-pdf
August 04, 2010 - Comparing errors in ED computer-assisted vs
conventional pediatric drug dosing and administration.
August 4, 2010
Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug
dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.1016/j.ajem.2009.02.009.
https://ps…
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psnet.ahrq.gov/node/41959/psn-pdf
January 16, 2013 - Use of FMEA analysis to reduce risk of errors in
prescribing and administering drugs in paediatric wards:
a quality improvement report.
January 16, 2013
Lago P, Bizzarri G, Scalzotto F, et al. Use of FMEA analysis to reduce risk of errors in prescribing and
administering drugs in paediatric wards: a quality improv…
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/node/43765/psn-pdf
February 04, 2015 - Differences in medication knowledge and risk of errors
between graduating nursing students and working
registered nurses: comparative study.
February 4, 2015
Simonsen BO, Daehlin GK, Johansson I, et al. Differences in medication knowledge and risk of errors
between graduating nursing students and working registere…
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Spotlight Case July 2008
Spotlight Case
A Weighty Mistake
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Source and Credits
This presentation is based on the March 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…