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psnet.ahrq.gov/node/33966/psn-pdf
August 01, 2017 - Enhancing Patient Safety and Reducing Errors in Health
Care.
August 1, 2017
Scheffler A; Zipperer LA, eds. Chicago, IL: National Patient Safety Foundation; 1999. ISBN:
9781579470555.
https://psnet.ahrq.gov/issue/enhancing-patient-safety-and-reducing-errors-health-care
The proceedings from the 1998 Annenberg meeti…
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psnet.ahrq.gov/node/35173/psn-pdf
June 27, 2016 - Medication Safety: A Guide for Health Care Facilities.
June 27, 2016
Manasse HR Jr, Thompson KK. Bethesda, MD: American Society of Health-System Pharmacists; 2005.
ISBN 9781585280896.
https://psnet.ahrq.gov/issue/medication-safety-guide-health-care-facilities
This book provides an in-depth introduction to implemen…
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psnet.ahrq.gov/node/36748/psn-pdf
September 27, 2017 - Medication safety in a psychiatric hospital.
September 27, 2017
Rothschild JM, Mann K, Keohane C, et al. Medication safety in a psychiatric hospital. Gen Hosp Psychiatry.
2007;29(2):156-62.
https://psnet.ahrq.gov/issue/medication-safety-psychiatric-hospital
The authors analyzed the incidence and type of medication…
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psnet.ahrq.gov/node/34009/psn-pdf
November 12, 2014 - Consumer Safe Medicine.
November 12, 2014
Plymouth Meeting, PA; Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismps-safe-medicine
ISMP's electronic consumer medication safety newsletter is published six times a year and its content aims
to engage patients and families in reducing medication…
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psnet.ahrq.gov/node/37561/psn-pdf
September 30, 2015 - Important Warnings and Instructions for Heparin Sodium
Injection (Baxter).
September 30, 2015
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2008.
https://psnet.ahrq.gov/issue/important-warnings-and-instructions-heparin-sodium-injection-baxter
This announcement update alert…
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psnet.ahrq.gov/node/36355/psn-pdf
October 27, 2010 - Paramedic self-reported medication errors.
October 27, 2010
Vilke GM, Tornabene S, Stepanski B, et al. Paramedic self-reported medication errors. Prehosp Emerg
Care. 2006;10(4):457-462.
https://psnet.ahrq.gov/issue/paramedic-self-reported-medication-errors
The researchers surveyed paramedics and found that 9% made…
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psnet.ahrq.gov/node/36943/psn-pdf
May 08, 2018 - Remote CPOE error—a situation that's more than
remotely possible.
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2007;12:1-3.
https://psnet.ahrq.gov/issue/remote-cpoe-error-situation-thats-more-remotely-possible
This article describes a wrong-patient drug error that was prescribed using a co…
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psnet.ahrq.gov/node/39884/psn-pdf
September 29, 2010 - New dosing recommendations to prevent potential
Valcyte (valganciclovir) overdose in pediatric transplant
patients.
September 29, 2010
United States Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/new-dosing-recommendations-prevent-potential-valcyte-valganciclovir-
overdose-pediatric
This announc…
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psnet.ahrq.gov/node/40409/psn-pdf
April 27, 2011 - Year in review: medication mishaps in the elderly.
April 27, 2011
Peron EP, Marcum ZA, Boyce R, et al. Year in review: medication mishaps in the elderly. Am J Geriatr
Pharmacother. 2011;9(1):1-10. doi:10.1016/j.amjopharm.2011.01.003.
https://psnet.ahrq.gov/issue/year-review-medication-mishaps-elderly
This review a…
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psnet.ahrq.gov/node/38236/psn-pdf
May 24, 2015 - ReliOn insulin syringes for use with U-100 insulin (Tyco
Healthcare-Covidien).
May 24, 2015
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 6, 2008.
https://psnet.ahrq.gov/issue/relion-insulin-syringes-use-u-100-insulin-tyco-healthcare-covidien
This announcement recalls a misla…
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psnet.ahrq.gov/node/36642/psn-pdf
January 14, 2011 - Appropriate prescribing of medications: an eight-step
approach.
January 14, 2011
Pollock M, Bazaldua O, Dobbie AE. Appropriate prescribing of medications: an eight-step approach. Am
Fam Physician. 2007;75(2):231-236.
https://psnet.ahrq.gov/issue/appropriate-prescribing-medications-eight-step-approach
The authors …
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psnet.ahrq.gov/node/35396/psn-pdf
September 11, 2009 - Applying hierarchical task analysis to medication
administration errors.
September 11, 2009
Lane R, Stanton NA, Harrison DA. Applying hierarchical task analysis to medication administration errors.
Appl Ergon. 2006;37(5):669-79.
https://psnet.ahrq.gov/issue/applying-hierarchical-task-analysis-medication-administra…
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psnet.ahrq.gov/node/41091/psn-pdf
October 01, 2021 - ISMP List of High-Alert Medications in
Community/Ambulatory Healthcare.
October 1, 2021
Horsham, PA: Institute for Safe Medication Practices; 2021.
https://psnet.ahrq.gov/issue/ismp-list-high-alert-medications-communityambulatory-healthcare
This fact sheet provides a list of high-alert medications commonly used in…
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psnet.ahrq.gov/node/39577/psn-pdf
June 09, 2010 - ISMP medication error report analysis.
June 9, 2010
Cohen MR, Smetzer JL. Hosp Pharm. 2010:45(5);352-355.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-45
This monthly selection of error reports discusses incidents involving look-alike drug names, concentration
dosage error, and h…
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psnet.ahrq.gov/node/41595/psn-pdf
May 28, 2019 - Luer Connector Misconnections: Under-Recognized but
Potentially Dangerous Events.
May 28, 2019
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. November 19,
2008.
https://psnet.ahrq.gov/issue/luer-connector-misconnections-under-recognized-potentially-dangerous-events
This Web si…
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psnet.ahrq.gov/node/38094/psn-pdf
December 23, 2012 - Small patients, big consequences in medical errors.
December 23, 2012
Tarkan L. New York Times. September 14, 2008;Health section:7.
https://psnet.ahrq.gov/issue/small-patients-big-consequences-medical-errors
This article describes how medical errors may cause serious harm in pediatric patients and offers tips for
…
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psnet.ahrq.gov/node/37299/psn-pdf
June 13, 2011 - Mother claims hospital error kept her from newborn
daughter.
June 13, 2011
Barbella M. Drug Topics. October 8, 2007.
https://psnet.ahrq.gov/issue/mother-claims-hospital-error-kept-her-newborn-daughter
This article reports how a failure to perform medication reconciliation during patient transfer led to a mother
b…
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www.ahrq.gov/patient-safety/about/areas.html
February 01, 2018 - Patient Safety and Quality Areas
AHRQ funds research to improve patient safety and quality across all settings of care. We also develop practical, research-based tools and resources that help clinicians and others working in the nation’s hospitals, nursing homes, medical offices, and other settings make care sa…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide219.html
October 01, 2014 - 219. Helpful Web Sites (All Web sites listed are either government-sponsored organizations or nonprofit foundations) (Continued)
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
National Institute on Drug Abuse: www.nida.nih.gov
Office on Smoking and Health at the Ce…
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digital.ahrq.gov/ahrq-funded-projects/preventing-perioperative-medication-errors-and-adverse-drug-events-through-use/citation/systems
January 01, 2023 - A systems theoretic process analysis of the medication use process in the operating room.
Citation
Samost-Williams A, Nanji KC. A systems theoretic process analysis of the medication use process in the operating room. Anesthesiology. 2020 Aug;133(2):332-341. doi: 10.1097/ALN.0000000000003376. PMID: 32…