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psnet.ahrq.gov/node/45595/psn-pdf
April 19, 2017 - Estimating deaths due to medical error: the ongoing
controversy and why it matters.
April 19, 2017
Shojania KG, Dixon-Woods M. Estimating deaths due to medical error: the ongoing controversy and why it
matters. BMJ Qual Saf. 2017;26(5):423-428. doi:10.1136/bmjqs-2016-006144.
https://psnet.ahrq.gov/issue/estimating…
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psnet.ahrq.gov/node/37254/psn-pdf
January 02, 2017 - Creating a fair and just culture: one institution's path
toward organizational change.
January 2, 2017
Connor M, Duncombe D, Barclay E, et al. Creating a fair and just culture: one institution's pat toward
organizational change. Jt Comm J Qual Patient Saf. 2007;33(10):617-24.
https://psnet.ahrq.gov/issue/creating-…
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psnet.ahrq.gov/node/47330/psn-pdf
September 19, 2018 - Patient and consumer safety risks when using
conversational assistants for medical information: an
observational study of Siri, Alexa, and Google Assistant.
September 19, 2018
Bickmore TW, Trinh H, Olafsson S, et al. Patient and consumer safety risks when using conversational
assistants for medical information: an…
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psnet.ahrq.gov/node/37842/psn-pdf
November 20, 2017 - An epistemology of patient safety research: a framework
for study design and interpretation.
November 20, 2017
Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design
and interpretation. Part 4. One size does not fit all. Quality and Safety in Health Care. 2008;17(…
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psnet.ahrq.gov/node/47671/psn-pdf
January 01, 2019 - Racial, ethnic, and socioeconomic disparities in patient
safety events for hospitalized children.
December 19, 2018
Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient
Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1-5. doi:10.1542/hpeds.2018-0131…
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psnet.ahrq.gov/node/46173/psn-pdf
August 20, 2018 - Advances in Patient Safety and Medical Liability.
August 20, 2018
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality;
2017. AHRQ Publication No. 17-0017-EF.
https://psnet.ahrq.gov/issue/advances-patient-safety-and-medical-liability
This publication describes the re…
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psnet.ahrq.gov/node/41816/psn-pdf
September 26, 2016 - Designing for distractions: a human factors approach to
decreasing interruptions at a centralised medication
station.
September 26, 2016
Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing
interruptions at a centralised medication station. BMJ Qual Saf. 2012;…
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psnet.ahrq.gov/node/39489/psn-pdf
June 11, 2010 - What happens between visits? Adverse and potential
adverse events among a low-income, urban, ambulatory
population with diabetes.
June 11, 2010
Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse
events among a low-income, urban, ambulatory population with diabetes. Qua…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - 4 factors:
Informing providers the point of care, allowing them to choose best and most affordable drugs … At Henry Ford Health System, clinical decision support was associated with increased use of generic drugs … with E-prescribing
Experts have recommended all e-prescribing systems use standard nomenclature for drugs
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psnet.ahrq.gov/node/41951/psn-pdf
September 07, 2016 - psnet.ahrq.gov/issue/examining-increase-drug-shortages
https://psnet.ahrq.gov/issue/shortage-perioperative-drugs-implications-anesthesia-practice-and-patient-safety
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psnet.ahrq.gov/issue/documentation-drug-allergy-drug-chart-patients-presenting-surgery
August 20, 2018 - Study
Documentation of drug allergy on drug chart in patients presenting for surgery.
Citation Text:
Farooq M, Kirke C, Foley K. Documentation of drug allergy on drug chart in patients presenting for surgery. Ir J Med Sci. 2008;177(3):243-5. doi:10.1007/s11845-008-0166-7.
Copy Citati…
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psnet.ahrq.gov/node/44644/psn-pdf
February 14, 2017 - accompanying editorial notes that the FDA is under pressure to
relax restrictions on marketing of drugs
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psnet.ahrq.gov/node/40548/psn-pdf
March 23, 2012 - potentially-inappropriate-medications-defined-stopp-criteria-and-risk-adverse-
drug-events
Many medications, particularly sedatives and other drugs
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - These regimens can involve multiple drugs administered in repetitive cycles, and are adjusted periodically … addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical … products or medical devices. … July 23, 2014
Characteristics of medication errors with parenteral cytotoxic drugs. … February 1, 2012
Computerized physician order entry of injectable antineoplastic drugs
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - It is well known that high doses of opioids as well as the combination of multiple opioids, illicit drugs … .( 1 ) The remaining 10% of patients seeing multiple doctors and typically involved in diversion of drugs … The combination of multiple drugs along with comorbid conditions and social instability should have been … addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical … products or medical devices.
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psnet.ahrq.gov/node/36364/psn-pdf
February 14, 2017 - In this study,
those drugs and digoxin accounted for nearly one-third of ADEs requiring hospitalization
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psnet.ahrq.gov/node/37112/psn-pdf
May 26, 2011 - While the study results are promising, one caveat is that the system was not used for high-risk
drugs
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - first step in pharmacological management of delirium is to discontinue or reduce doses of psychoactive drugs … Drugs that could cause or worsen delirium should be discontinued or doses adjusted. … sedative hypnotics, anticholinergics, corticosteroids, polypharmacy, withdrawal of alcohol or other drugs … Renal, hepatic, and thyroid function Cultures of urine, blood, sputum Concentrations of suspected drugs … from delirium Management Actions Drug adjustments Reduce or remove psychoactive drugs
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - involved opioids – a 12% increase from 2016. 1 This opioid overdose epidemic is due to use of illicit drugs … , highly potent synthetic opioids, mixing of illicit and prescription opioid or sedative drugs, and misused … Prescription drugs: prescribers: naloxone hydrochloride and other FDA-approved drugs , AB 2760 , 2018
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psnet.ahrq.gov/issue/analysis-overridden-alerts-drug-drug-interaction-detection-system
June 30, 2011 - Study
Analysis of overridden alerts in a drug–drug interaction detection system.
Citation Text:
Mille F, Schwartz C, Brion F, et al. Analysis of overridden alerts in a drug-drug interaction detection system. Int J Qual Health Care. 2008;20(6):400-5. doi:10.1093/intqhc/mzn038.
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