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digital.ahrq.gov/location/usa-wi-west-bend
January 01, 2023 - USA, WI, West Bend
Improving Patient Safety/Quality with Health Information Technology Implementation
Description
Implemented an Epic health IT system and diffused the system community-wide; identified the prevalence of medication errors, near misses, and preventable adverse d…
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digital.ahrq.gov/location/usa-mi-traverse-city
January 01, 2023 - USA, MI, Traverse City
Bar Coding for Patient Safety in Northern Michigan
Description
Implemented a bar-coding application to an existing integrated health IT network that alerts providers to potential drug interactions and allergic reactions, tracks "near misses," and provide…
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psnet.ahrq.gov/node/39044/psn-pdf
March 12, 2010 - Relenza (zanamivir) inhalation powder.
March 12, 2010
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.
https://psnet.ahrq.gov/issue/relenza-zanamivir-inhalation-powder
This alert notifies health care providers of the potential for patient harm if a particular inhalation po…
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psnet.ahrq.gov/node/42126/psn-pdf
November 30, 2016 - 2015 Patient Safety Core Topics and Tips.
November 30, 2016
Chicago, IL: American Society for Healthcare Risk Management; 2015.
https://psnet.ahrq.gov/issue/2015-patient-safety-core-topics-and-tips
This fact sheet lists 10 patient safety concerns such as adverse drug events and offers tips to address
them.
https:…
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psnet.ahrq.gov/node/41757/psn-pdf
January 25, 2018 - BeSafeRx: Know Your Online Pharmacy.
January 25, 2018
US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/besaferx-know-your-online-pharmacy
This Web site raises awareness of risks associated with buying medications from online pharmacies and
offers resources to help identify whether an online pharm…
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www.ahrq.gov/sites/default/files/2024-01/gurwitz-report.pdf
January 01, 2024 - Final Progress Report: Enhancing the Safety of Warfarin in the Nursing Home
Project Title: Enhancing the Safety of Warfarin in the Nursing Home
Principal Investigator: Jerry H. Gurwitz, MD
Principal Team Members: Jerry Gurwitz, MD; Terry S. Field, DSc; Jennifer Tjia, MD,
MSCE; Kathleen M. Mazor, EdD; Leslie R. Ha…
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psnet.ahrq.gov/node/36915/psn-pdf
May 30, 2007 - Fatal error sparks debate over punitive measures.
May 30, 2007
Fernandez J. Drug Topics. May 7, 2007.
https://psnet.ahrq.gov/issue/fatal-error-sparks-debate-over-punitive-measures
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken
against the pharmacist invo…
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psnet.ahrq.gov/node/38342/psn-pdf
September 08, 2022 - Consumermedsafety.org
September 8, 2022
Institute for Safe Medication Practices; 5200 Butler Pike, Plymouth Meeting, PA 19462.
https://psnet.ahrq.gov/issue/consumermedsafetyorg
This redesigned Web site provides information about drug safety alerts and allows consumers to help
report and prevent medication errors.
…
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psnet.ahrq.gov/node/36872/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-12
This monthly selection of medication error reports provides examples of problems related to medication
misadministration, drug shortages, and the appropriate use of the "five rights"…
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psnet.ahrq.gov/node/35533/psn-pdf
February 22, 2010 - Essay: the political logic of regulatory error.
February 22, 2010
Carpenter D, Ting MM. Essay: the political logic of regulatory error. Nat Rev Drug Discov. 2005;4(10):819-
23.
https://psnet.ahrq.gov/issue/essay-political-logic-regulatory-error
The authors draw on political science to discuss factors that contribu…
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psnet.ahrq.gov/node/38151/psn-pdf
March 18, 2010 - Medication errors associated with documented allergies.
March 18, 2010
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
https://psnet.ahrq.gov/issue/medication-errors-associated-documented-allergies
This article analyzed reports of medication errors due to patient allergies and found that lack of patient o…
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psnet.ahrq.gov/node/35883/psn-pdf
July 01, 2009 - Bar Code Label Requirements for Blood and Blood
Components.
July 1, 2009
FDA; Food and Drug Administration; CBER; Center for Biologics Evaluation and Research.
https://psnet.ahrq.gov/issue/bar-code-label-requirements-blood-and-blood-components
This FAQ answers questions related to the FDA machine-readable bar-codi…
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digital.ahrq.gov/sites/default/files/docs/resource/Laminated_Reminder_Card.pdf
June 16, 2021 - laminated reminder card
Exclusions
• Terminal Status (Hospice Patients)
• Incarceration (Prison Population)
• New wound (less than 3 weeks)
• Wound already scheduled for
surgery
• Patient doesn’t live in a study
county
Telewound Care Study contact:
Cynthia Scheideman-Miller
Phone: (405) 713…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide09.html
October 01, 2014 - 9. Funded by:
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
Agency for Healthcare Research and Quality
National Cancer Institute
National Heart, Lung & Blood Institute
National Institute on Drug Abuse
Centers for Disease Control and Prevention
The Robert …
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-overview/slide06.html
October 01, 2014 - 6. Funded by
Treating Tobacco Use and Dependence: 2008 Update Overview
Text version of slide presentation.
Agency for Healthcare Research and Quality
National Cancer Institute
National Heart, Lung & Blood Institute
National Institute on Drug Abuse
Centers for Disease Control and Prevention
The…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - Moved Too Soon
October 1, 2004
Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/moved-too-soon
The Case
A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours
after arriving, while the patient was still groggy from anesthesia, a nurs…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
View more articles from the same authors.
Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Alan Forster, M…
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…