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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/860724/psn-pdf
January 17, 2024 - Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient?
January 17, 2024
Kneifati-Hayek JZ, Geist E, Applebaum JR, et al. Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient? BMJ Qual Saf. 2024;33(2):132-135. doi:10.1136/bmjqs-2023-
016…
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psnet.ahrq.gov/node/74151/psn-pdf
January 01, 2022 - Nursing interventions to reduce medication errors in
paediatrics and neonates: systematic review and meta-
analysis.
December 8, 2021
Marufu TC, Bower R, Hendron E, et al. Nursing interventions to reduce medication errors in paediatrics and
neonates: systematic review and meta-analysis. J Pediatr Nurs. 2022;62:e13…
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psnet.ahrq.gov/node/848366/psn-pdf
May 03, 2023 - The effect of documenting patient weight in kilograms on
pediatric medication dosing errors in emergency medical
services.
May 3, 2023
Ward CE, Taylor M, Keeney C, et al. The effect of documenting patient weight in kilograms on pediatric
medication dosing errors in emergency medical services. Prehosp Emerg Care. 2…
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psnet.ahrq.gov/node/837890/psn-pdf
August 24, 2022 - Accuracy of pressure ulcer events in US nursing home
ratings.
August 24, 2022
Chen Z, Gleason LJ, Sanghavi P. Accuracy of pressure ulcer events in US nursing home ratings. Med
Care. 2022;60(10):775-783. doi:10.1097/mlr.0000000000001763.
https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ra…
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psnet.ahrq.gov/node/60726/psn-pdf
January 01, 2021 - User-testing guidelines to improve the safety of
intravenous medicines administration: a randomised in
situ simulation study.
July 29, 2020
Jones MD, McGrogan A, Raynor DK, et al. User-testing guidelines to improve the safety of intravenous
medicines administration: a randomised in situ simulation study. BMJ Qual …
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/46046/psn-pdf
April 19, 2017 - Teaching students to administer medications safely.
April 19, 2017
Koharchik L, Flavin PM. Teaching Students to Administer Medications Safely. Am J Nurs. 2017;117(1):62-
66. doi:10.1097/01.NAJ.0000511573.73435.72.
https://psnet.ahrq.gov/issue/teaching-students-administer-medications-safely
Students are likely to m…
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect adverse drug
events in the hospital setting.
March 10, 2011
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical
event monitor signals used to detect adverse …
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psnet.ahrq.gov/node/44082/psn-pdf
April 22, 2015 - Impact of including readmissions for qualifying events in
the Patient Safety Indicators.
April 22, 2015
Davies SM, Saynina O, Baker LC, et al. Impact of including readmissions for qualifying events in the patient
safety indicators. Am J Med Qual. 2015;30(2):114-8. doi:10.1177/1062860613518341.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/45986/psn-pdf
March 29, 2017 - Pediatric prehospital medication dosing errors: a national
survey of paramedics.
March 29, 2017
Hoyle JD, Crowe RP, Bentley MA, et al. Pediatric prehospital medication dosing errors: a national survey of
paramedics. Prehosp Emerg Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/45547/psn-pdf
October 05, 2016 - Sick children face potentially deadly danger: medication
errors.
October 5, 2016
Furfaro H. Wall Street Journal. September 25, 2016.
https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors
Medication errors in pediatric care are common in the hospital and at home. This newspaper…
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psnet.ahrq.gov/node/865344/psn-pdf
March 27, 2024 - Use of computerized physician order entry with clinical
decision support to prevent dose errors in pediatric
medication orders: a systematic review.
March 27, 2024
Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical
decision support to prevent dose errors in pedia…
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psnet.ahrq.gov/node/43047/psn-pdf
August 02, 2015 - Hospital readmission after noncardiac surgery: the role of
major complications.
August 2, 2015
Glance LG, Kellermann AL, Osler T, et al. Hospital readmission after noncardiac surgery: the role of major
complications. JAMA Surg. 2014;149(5):439-45.
https://psnet.ahrq.gov/issue/hospital-readmission-after-noncardiac-…
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - information technology will be far exceeded by the removal of mathematical errors and oversights in calculating
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - This study uses an innovative approach to analyze Hospital SOPS results longitudinally by calculating
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psnet.ahrq.gov/node/845637/psn-pdf
March 08, 2023 - Using Failure Mode, Effect and Criticality Analysis to
improve safety in the cancer treatment prescription and
administration process.
March 8, 2023
Buja A, De Luca G, Ottolitri K, et al. Using Failure Mode, Effect and Criticality Analysis to improve safety in
the cancer treatment prescription and administration p…
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psnet.ahrq.gov/node/50736/psn-pdf
December 11, 2019 - Prevalence and nature of medication errors and
preventable adverse drug events in paediatric and
neonatal intensive care settings: a systematic review.
December 11, 2019
Alghamdi AA, Keers RN, Sutherland A, et al. Prevalence and Nature of Medication Errors and Preventable
Adverse Drug Events in Paediatric and Neon…
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psnet.ahrq.gov/node/842421/psn-pdf
January 11, 2023 - Weight and size descriptors for drug dosing: too many
options and too many errors.
January 11, 2023
Erstad BL, Romero AV, Barletta JF. Weight and size descriptors for drug dosing: Too many options and too
many errors. Am J Health Syst Pharm. 2023;80(2):87-91. doi:10.1093/ajhp/zxac283.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/issue/transitions-care-toc-portal
March 07, 2018 - Multi-use Website
Transitions of Care (TOC) Portal.
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February 27, 2013
This Web site provides resources for clinicians and patien…