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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-27
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR. Hosp Pharm. 2008;43:547-550, 554.
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psnet.ahrq.gov/issue/technology-education-and-safety-0
December 02, 2020 - Special or Theme Issue
Technology, Education and Safety.
Citation Text:
Technology, Education and Safety. Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765
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psnet.ahrq.gov/issue/why-pay-mistakes
July 20, 2011 - Newspaper/Magazine Article
Why pay for mistakes?
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September 5, 2007
View more articles from the same authors.
Recently, CMS ru…
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psnet.ahrq.gov/issue/patient-safety-risk-and-quality
March 10, 2021 - Multi-use Website
Patient Safety, Risk and Quality.
Citation Text:
Patient Safety, Risk and Quality. ECRI
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psnet.ahrq.gov/issue/patient-safety-old-and-new-issue
June 01, 2011 - Special or Theme Issue
Patient Safety: An Old and New Issue.
Citation Text:
Patient Safety: An Old and New Issue. Bagnara S; Tartaglia R, eds. Theor Issues Ergon Sci. 2023;8(5):365-507.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-33
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.
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psnet.ahrq.gov/issue/ahrq-2009-annual-conference
December 24, 2008 - Meeting/Conference Proceedings
AHRQ 2009 Annual Conference.
Citation Text:
AHRQ 2009 Annual Conference. Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/issue/health-literacy-0
December 24, 2008 - Multi-use Website
Health Literacy.
Citation Text:
Health Literacy. Agency for Healthcare Research and Quality
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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/node/33647/psn-pdf
March 01, 2007 - The Role of the Patient in Improving Patient Safety
March 1, 2007
Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
Perspective
Patients have three roles in improving patient safety: helping to ensure thei…
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - Transfusion "Slip"
February 1, 2004
Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/transfusion-slip
The Case
A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma
center after a half-ton truck that had skidded out of control struck…
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psnet.ahrq.gov/node/50927/psn-pdf
February 21, 2020 - Patient Safety in Primary Care
February 21, 2020
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-primary-care
Introduction
A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare …
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psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - Drugs . 2015;75(4):353-365. [ Free full text ] Perry EC. … CNS Drugs . 2014;28(5):401-410. [ Free full text ] Crispo AL, Daley MJ, Pepin JL, et al.
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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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