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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - effective across conditions, efforts to reduce the likelihood of an incident such as this one should be
directed
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psnet.ahrq.gov/node/74227/psn-pdf
January 12, 2022 - Prevalence, contributory factors and severity of
medication errors associated with direct-acting oral
anticoagulants in adult patients: a systematic review and
meta-analysis.
January 12, 2022
Al Rowily A, Jalal Z, Price MJ, et al. Prevalence, contributory factors and severity of medication errors
associated with …
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psnet.ahrq.gov/node/851349/psn-pdf
July 12, 2023 - Contributory factors and patient harm including deaths
associated direct acting oral anticoagulants (DOACs)
medication incidents: evaluation of real world data
reported to the national reporting and learning system.
July 12, 2023
Rowily AA, Jalal Z, Paudyal V. Contributory factors and patient harm including deaths…
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psnet.ahrq.gov/node/73186/psn-pdf
April 28, 2021 - Inappropriate dosing of direct oral anticoagulants in
patients with atrial fibrillation.
April 28, 2021
Sugrue A, Sanborn D, Amin M, et al. Inappropriate dosing of direct oral anticoagulants in patients with atrial
fibrillation. Am J Cardiol. 2020;144:52-59. doi:10.1016/j.amjcard.2020.12.062.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/848822/psn-pdf
May 10, 2023 - Inappropriate prescriptions of direct oral anticoagulants
(DOACs) in hospitalized patients: a narrative review.
May 10, 2023
van der Horst SFB, van Rein N, van Mens TE, et al. Inappropriate prescriptions of direct oral
anticoagulants (DOACs) in hospitalized patients: a narrative review. Thromb Res. 2023;231:135-140…
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psnet.ahrq.gov/issue/contributory-factors-and-patient-harm-including-deaths-associated-direct-acting-oral
January 12, 2022 - Study
Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system.
Citation Text:
Rowily AA, Jalal Z, Paudyal V. Contributory factors…
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psnet.ahrq.gov/node/854375/psn-pdf
October 11, 2023 - Multicomponent pharmacist intervention did not reduce
clinically important medication errors for ambulatory
patients initiating direct oral anticoagulants.
October 11, 2023
Kapoor A, Patel P, Mbusa D, et al. Multicomponent pharmacist intervention did not reduce clinically
important medication errors for ambulatory…
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psnet.ahrq.gov/node/74206/psn-pdf
December 22, 2021 - Direct oral anticoagulant-related medication incidents and
pharmacists' interventions in hospital in-patients:
evaluation using Reason's accident causation theory.
December 22, 2021
Haque H, Alrowily A, Jalal Z, et al. Direct oral anticoagulant-related medication incidents and pharmacists’
interventions in hospita…
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psnet.ahrq.gov/node/48181/psn-pdf
August 07, 2019 - Managing the risks of direct oral anticoagulants.
August 7, 2019
Sentinel Event Alert. July 30, 2019;(61):1-5.
https://psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral
anticoagulants (DOACs) require less…
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psnet.ahrq.gov/issue/safety-participation-direct-care-level-results-patient-questionnaire
August 26, 2020 - Study
Safety participation at the direct care level: results of a patient questionnaire.
Citation Text:
Duhn L, Gumapac N, Medves J. Safety participation at the direct care level: results of a patient questionnaire. Patient Exp J. 2021;8(1):59-68. doi:10.35680/2372-0247.1506.
Copy Cita…
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psnet.ahrq.gov/node/50401/psn-pdf
October 02, 2019 - Discrepant advanced directives and code status orders: a
preventable medical error.
October 2, 2019
Meisenberg B, Zaidi S, Franks L, et al. Discrepant Advanced Directives and Code Status Orders: A
Preventable Medical Error. J Hosp Med. 2019;14(10):716-718. doi:10.12788/jhm.3244.
https://psnet.ahrq.gov/issue/discre…
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psnet.ahrq.gov/issue/improving-rapid-response-systems-progress-issues-and-future-directions
January 26, 2022 - Meeting/Conference Proceedings
Improving rapid response systems: progress, issues, and future directions.
Citation Text:
Ovretveit J, Suffoletto J-A. Improving rapid response systems: progress, issues, and future directions.
Copy Citation
Format:
Google Scholar PubMed BibTe…
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - Jones: We hear more about the verbal and physical violence from patients and families directed toward … This focus goes hand in hand with some of the policy work that could be directed at addressing workplace … (NIOSH) defines workplace violence as violent acts, including physical assaults and verbal threats, directed
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - (NIOSH) defines workplace violence as violent acts, including physical assaults and verbal threats, directed … Jones: We hear more about the verbal and physical violence from patients and families directed toward … This focus goes hand in hand with some of the policy work that could be directed at addressing workplace
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psnet.ahrq.gov/node/866348/psn-pdf
July 24, 2024 - How can interventions more directly address drivers of
unprofessional behaviour between healthcare staff?
July 24, 2024
Aunger JA, Abrams R, Mannion R, et al. How can interventions more directly address drivers of
unprofessional behaviour between healthcare staff? BMJ Open Qual. 2024;13(3):e002830.
doi:10.1136/bmj…
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psnet.ahrq.gov/node/866859/psn-pdf
October 02, 2024 - Severe hypertension in pregnancy: progress made and
future directions for patient safety, quality improvement,
and implementation of a patient safety bundle.
October 2, 2024
Prior A, Taylor I, Gibson KS, et al. Severe hypertension in pregnancy: progress made and future directions
for patient safety, quality improv…
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psnet.ahrq.gov/issue/emergency-physicians-views-direct-notification-laboratory-and-radiology-results-patients
March 23, 2012 - Study
Emergency physicians' views of direct notification of laboratory and radiology results to patients using the internet: a multisite survey.
Citation Text:
Callen J, Giardina TD, Singh H, et al. Emergency physicians' views of direct notification of laboratory and radiology results to…
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psnet.ahrq.gov/node/837631/psn-pdf
July 06, 2022 - The impact of an electronic alert to reduce the risk of co-
prescription of low molecular weight heparins and direct
oral anticoagulants.
July 6, 2022
Brown A, Cavell G, Dogra N, et al. The impact of an electronic alert to reduce the risk of co-prescription of
low molecular weight heparins and direct oral anticoag…
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psnet.ahrq.gov/node/60849/psn-pdf
January 01, 2021 - Associations between double-checking and medication
administration errors: a direct observational study of
paediatric inpatients.
August 26, 2020
Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and medication administration
errors: a direct observational study of paediatric inpatients. BM…
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psnet.ahrq.gov/node/866167/psn-pdf
June 19, 2024 - Risk factors associated with medication administration
errors in children: a prospective direct observational
study of paediatric inpatients.
June 19, 2024
Westbrook JI, Li L, Woods AL, et al. Risk factors associated with medication administration errors in
children: a prospective direct observational study of pae…