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psnet.ahrq.gov/node/45121/psn-pdf
September 27, 2016 - Factors influencing a nurse's decision to question
medication administration in a neonatal clinical care unit.
September 27, 2016
Aydon L, Hauck Y, Zimmer M, et al. Factors influencing a nurse's decision to question medication
administration in a neonatal clinical care unit. J Clin Nurs. 2016;25(17-18):2468-77.
do…
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psnet.ahrq.gov/node/47531/psn-pdf
June 19, 2019 - Patient Safety.
June 19, 2019
Health Aff (Millwood). 2018;37(11):1723-1908.
https://psnet.ahrq.gov/issue/patient-safety-14
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This
special issue of Health Affairs, published 20 years after that report, highlights achie…
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psnet.ahrq.gov/node/47266/psn-pdf
August 08, 2018 - Outpatient opioid prescriptions for children and opioid-
related adverse events.
August 8, 2018
Chung CP, Callahan T, Cooper WO, et al. Outpatient Opioid Prescriptions for Children and Opioid-Related
Adverse Events. Pediatrics. 2018;142(2):e20172156. doi:10.1542/peds.2017-2156.
https://psnet.ahrq.gov/issue/outpati…
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psnet.ahrq.gov/node/38961/psn-pdf
September 01, 2016 - An empirical model to estimate the potential impact of
medication safety alerts on patient safety, health care
utilization, and cost in ambulatory care.
September 1, 2016
Weingart SN, Simchowitz B, Padolsky H, et al. An empirical model to estimate the potential impact of
medication safety alerts on patient safety,…
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psnet.ahrq.gov/node/48112/psn-pdf
July 10, 2019 - Intravenous infusion administration: a comparative study
of practices and errors between the United States and
England and their implications for patient safety.
July 10, 2019
Blandford A, Dykes PC, Franklin BD, et al. Intravenous Infusion Administration: A Comparative Study of
Practices and Errors Between the Uni…
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psnet.ahrq.gov/node/48130/psn-pdf
August 07, 2019 - Adverse events in long-term care residents transitioning
from hospital back to nursing home.
August 7, 2019
Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From
Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261.
doi:10.1001/jamainternmed.2019.2005.
…
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psnet.ahrq.gov/node/42968/psn-pdf
February 26, 2014 - From physician intent to the pharmacy label: prevalence
and description of discrepancies from a cross-sectional
evaluation of electronic prescriptions.
February 26, 2014
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and
description of discrepancies from a cross-se…
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psnet.ahrq.gov/node/40289/psn-pdf
March 16, 2011 - Unintentional therapeutic errors involving insulin in the
ambulatory setting reported to poison centers.
March 16, 2011
Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory
setting reported to poison centers. Ann Pharmacother. 2011;45(1):17-22. doi:10.1345/aph.1…
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psnet.ahrq.gov/node/41964/psn-pdf
April 17, 2013 - Use of HIT for adverse event reporting in nursing homes:
barriers and facilitators.
April 17, 2013
Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and
facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.003.
https://psnet.ahrq.gov/issue/u…
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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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