-
psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - right after admission, it would have been appropriate to administer one of the atypical antipsychotic drugs … orally, instead of oral, intramuscular (IM), or IV haloperidol or other older, "typical" antipsychotic drugs … treatment, reserved for patients who fail to respond to one or two of the other atypical antipsychotic drugs … symptoms (EPS); the atypical drugs are much less likely to produce these adverse effects. … QTc interval is 440 ms or longer, and patients have electrolyte disturbance or are receiving other drugs
-
psnet.ahrq.gov/node/40144/psn-pdf
September 29, 2017 - This study targeted prescribing for drugs classified as requiring a black box warning by
implementing … Certain specific alerts, such as
warning against prescribing drugs contraindicated in pregnancy or those
-
psnet.ahrq.gov/issue/recommendations-improve-usability-drug-drug-interaction-clinical-decision-support-alerts
February 14, 2024 - April 24, 2018
Impact of interactions between drugs and laboratory test results on diagnostic
-
psnet.ahrq.gov/issue/changes-prescription-and-over-counter-medication-and-dietary-supplement-use-among-older
May 06, 2020 - more medications, they are at higher risk for adverse effects from supplements and over-the-counter drugs … June 19, 2019
Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable
-
psnet.ahrq.gov/issue/two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-events
March 24, 2021 - describes how the health care organization implemented changes (including using different bags for drugs … event and made further revisions when the second incident occurred 7 years later (such as ensuring drugs
-
psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - Vasoactive drugs were administered to recover the blood pressure and the patient was ventilated with … Different drugs require different concentrations, and a typical anesthetic case requires the use of at … least four medications. 7 A study that measured the concentration of diluted drugs in the OR revealed … Some drugs require serial dilution and may come in different units of weight (e.g., mcg/ml vs mg/ml). … Leading to Difficult Intubation and Severe Hypoxemia
June 30, 2021
Meitheal Pharmaceuticals
-
psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - The packages of both drugs, made by the same manufacturer, were
almost identical. … However, when one
realizes that the brand name of digoxin is Lanoxin®, and that in this case both drugs … Both are drugs that would be stocked on a typical neonatal unit, and the doses used are
similar. … Packaging and look-alike/sound-alike drugs are thought to be important contributing factors. … The effects of a patients’ own drugs scheme on the incidence and severity of
medication administration
-
psnet.ahrq.gov/issue/best-practices-developing-proprietary-names-human-prescription-drug-products-guidance
January 13, 2021 - August 9, 2017
Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals. … About The Topic
Non-Health Care Professionals
Medication Safety
Look-Alike, Sound-Alike Drugs
-
psnet.ahrq.gov/issue/timing-and-interventions-emergency-teams-during-merit-study
June 02, 2010 - Australian study required critical care interventions such as airway management or use of inotropic drugs … January 15, 2009
Impact of interactions between drugs and laboratory test results on
-
psnet.ahrq.gov/issue/improving-self-reporting-adverse-drug-events-west-virginia-hospital
March 10, 2011 - determined that incident reports were made for less than 4% of adverse drug events (ADEs) involving rescue drugs … October 1, 2014
Look alike/sound alike drugs: a literature review on causes and solutions
-
psnet.ahrq.gov/issue/guided-prescription-psychotropic-medications-geriatric-inpatients
February 04, 2018 - Results indicate increased prescription of recommended doses, decreased prescription of nonrecommended drugs … May 27, 2011
Preventability of adverse drug events involving multiple drugs using publicly
-
psnet.ahrq.gov/issue/implementation-integrated-computerized-prescriber-order-entry-system-chemotherapy-multisite
August 30, 2023 - Variations in the administration of high-alert drugs can facilitate errors that result in patient harm … May 9, 2014
Computerized physician order entry of injectable antineoplastic drugs: an
-
psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
January 12, 2011 - involving prescribing for the wrong route (eg, orally instead of intravenously), and cardiovascular drugs … &M Cases
Surprise Wire
August 21, 2005
Cardiovascular drugs
-
psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - to an intravenous catheter may have deadly consequences. 2 Inadvertent intraarterial injection of drugs … Some drugs are very irritating to the endothelium and cause thrombosis and necrosis, while others are … Approaches to Improving Patient Safety Avoid injecting drugs and air bubbles into arterial lines All … This color coding was put in place because unintended IV infusion of local anesthetic drugs intended … Inadvertent epidural injection of drugs for intravenous use. A review.
-
psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - anesthesia than in other medical fields because anesthesiologists and nurse anesthetists administer drugs … An anesthesiologist may, in fact, inject up to a half million doses of different drugs in his/her professional … Smaller ampules for more concentrated medications
Concentrated solutions of drugs should be provided … http://www.fda.gov/Drugs/DrugSafety/ucm330695.htm . Accessed January 2021. … WebM&M Cases
Distraction of the Anesthesiologist and Lack of Resuscitation Drugs
-
psnet.ahrq.gov/issue/drug-drug-interactions-and-actual-harm-hospitalized-patients-multicentre-study-examining
August 26, 2020 - frequency of pDDI and cDDI orders did not differ between timeframes, although the likelihood of both drugs … Given the low prevalence of actual harm and the decreased likelihood of co-administration of drugs even
-
psnet.ahrq.gov/issue/cross-sectional-observational-study-high-override-rates-drug-allergy-alerts-inpatient-and
July 02, 2019 - A few classes of drugs accounted for a large proportion of overridden alerts, suggesting that enhancing … the accuracy of allergy warnings for these drugs could significantly reduce the overall burden of alerts
-
psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Doyle, MBBS Adverse reactions to drugs (including contrast media) occur frequently and were responsible … hospital annually between 1996 and 2000 (Hospital Episode Statistics) in the United Kingdom (UK).( 1 ) All drugs … suspected drug allergy, the following should be documented: generic and proprietary name of the drug or drugs … taken, or number of days on the drug before onset of the reaction; route of administration; and which drugs … Patients should expect and anticipate that both adverse drug reactions and allergies to drugs are appropriately
-
psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Some drugs are very irritating to the endothelium and cause thrombosis and
necrosis, while others are … Approaches to Improving Patient Safety
Avoid injecting drugs and air bubbles into arterial lines
All … who administer medications must be aware of the potential for serious thrombotic complications if
drugs … This color coding was put in place because unintended IV infusion of local
anesthetic drugs intended … Inadvertent epidural injection of drugs for intravenous use. A
review.
-
psnet.ahrq.gov/issue/medication-safety-ambulatory-chemotherapy-setting
February 18, 2011 - Chemotherapeutic drugs share the characteristic of providing life-saving benefits at the expense of substantial … May 19, 2014
Characteristics of medication errors with parenteral cytotoxic drugs.