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psnet.ahrq.gov/node/43327/psn-pdf
July 09, 2014 - Interprofessional learning for medication safety.
July 9, 2014
Hardisty J, Scott L, Chandler S, et al. Interprofessional learning for medication safety. Clin Teach.
2014;11(4):290-6. doi:10.1111/tct.12148.
https://psnet.ahrq.gov/issue/interprofessional-learning-medication-safety
This commentary describes the devel…
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psnet.ahrq.gov/node/41637/psn-pdf
February 20, 2013 - Codeine use in certain children after tonsillectomy and/or
adenoidectomy may lead to rare, but life-threatening
adverse events or death.
February 20, 2013
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 15, 2012. (Updated
February 20, 2013)
https://psnet.ahrq.gov/issue/codeine-us…
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psnet.ahrq.gov/node/36661/psn-pdf
March 22, 2010 - Heparin sodium injection 10,000 units/mL, and HEP-LOCK
U/P 10 units/mL medication errors.
March 22, 2010
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 6, 2007.
https://psnet.ahrq.gov/issue/heparin-sodium-injection-10000-unitsml-and-hep-lock-10-unitsml-medication-
errors
This …
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psnet.ahrq.gov/node/840494/psn-pdf
November 30, 2022 - Safety of anesthetic and perioperative medication
practices.
November 30, 2022
Meyer TA. Anesthesiology News. October 31, 2022.
https://psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices
Medication use in the surgical environment is complex and high-risk. This article describes steps tow…
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psnet.ahrq.gov/node/35271/psn-pdf
June 29, 2009 - Use of specific indicators to detect warfarin-related
adverse events.
June 29, 2009
Hartis CE, Gum MO, Lederer JW. Use of specific indicators to detect warfarin-related adverse events.
American Journal of Health-System Pharmacy. 2005;62(16). doi:10.2146/ajhp040404.
https://psnet.ahrq.gov/issue/use-specific-indic…
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psnet.ahrq.gov/node/35725/psn-pdf
July 14, 2010 - Characteristics of medication errors made by students
during the administration phase: a descriptive study.
July 14, 2010
Wolf ZR, Hicks RW, Serembus JF. Characteristics of medication errors made by students during the
administration phase: a descriptive study. J Prof Nurs. 2006;22(1):39-51.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/44529/psn-pdf
September 30, 2015 - Learning from no-fault treatment injury claims to improve
the safety of older patients.
September 30, 2015
Wallis KA. Learning from no-fault treatment injury claims to improve the safety of older patients. Ann Fam
Med. 2015;13(5):472-4. doi:10.1370/afm.1810.
https://psnet.ahrq.gov/issue/learning-no-fault-treatment…
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psnet.ahrq.gov/node/47049/psn-pdf
July 10, 2019 - Injectable Opioid Shortages: Suggestions for
Management and Conservation.
July 10, 2019
University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists.
https://psnet.ahrq.gov/issue/injectable-opioid-shortages-suggestions-management-and-conservation
Efforts to limit the availabilit…
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psnet.ahrq.gov/node/853250/psn-pdf
September 06, 2023 - ‘The Retrievals’ reveals painful experiences of female
patients are often ignored.
September 6, 2023
Desjardins L. PBS NewsHour. August 29, 2023.
https://psnet.ahrq.gov/issue/retrievals-reveals-painful-experiences-female-patients-are-often-ignored
Disregard for women’s pain is a persistent problem in health care. …
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psnet.ahrq.gov/node/45110/psn-pdf
May 11, 2016 - Hospital discharge: it's one of the most dangerous
periods for patients.
May 11, 2016
Rau J. Washington Post. April 29, 2016.
https://psnet.ahrq.gov/issue/hospital-discharge-its-one-most-dangerous-periods-patients
Transitions in care between inpatient and outpatient settings are an increasing concern for patient s…
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psnet.ahrq.gov/node/43738/psn-pdf
December 03, 2014 - Unverified patient-reported error: a false alarm can have
real consequences.
December 3, 2014
ISMP Medication Safety Alert! Acute care edition. November 20, 2014;19:1-3.
https://psnet.ahrq.gov/issue/unverified-patient-reported-error-false-alarm-can-have-real-consequences
Reviewing an incident involving a patient w…
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psnet.ahrq.gov/node/41377/psn-pdf
May 16, 2012 - What did the doctor say? Health literacy and recall of
medical instructions.
May 16, 2012
McCarthy D, Waite KR, Curtis LM, et al. What did the doctor say? Health literacy and recall of medical
instructions. Med Care. 2012;50(4):277-82. doi:10.1097/MLR.0b013e318241e8e1.
https://psnet.ahrq.gov/issue/what-did-doctor-…
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psnet.ahrq.gov/node/34627/psn-pdf
December 08, 2015 - Patient & Worker Safety.
December 8, 2015
Association of periOperative Registered Nurses.
https://psnet.ahrq.gov/issue/patient-worker-safety
This site hosts a guideline collection as a part of the Association of PeriOperative Registered Nurses'
(AORN) patient safety initiative targeting the needs of perioperative …
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psnet.ahrq.gov/node/38795/psn-pdf
April 08, 2011 - Cardiovascular medication errors in children.
April 8, 2011
Alexander DC, Bundy DG, Shore AD, et al. Cardiovascular medication errors in children. Pediatrics.
2009;124(1):324-32. doi:10.1542/peds.2008-2073.
https://psnet.ahrq.gov/issue/cardiovascular-medication-errors-children
This study found that diuretics and a…
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psnet.ahrq.gov/node/43151/psn-pdf
April 30, 2014 - Open for Better Care.
April 30, 2014
Health Quality & Safety Commission New Zealand.
https://psnet.ahrq.gov/issue/open-better-care
This Web site hosts tools and resources associated with a national campaign to augment patient care. The
initiative aims to build collaborative programs across New Zealand to reduce fa…
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psnet.ahrq.gov/node/42174/psn-pdf
May 15, 2013 - Strategies to reduce the risk of iatrogenic illness in
complex older adults.
May 15, 2013
Onder G, van der Cammen TJM, Petrovic M, et al. Strategies to reduce the risk of iatrogenic illness in
complex older adults. Age Ageing. 2013;42(3):284-91. doi:10.1093/ageing/aft038.
https://psnet.ahrq.gov/issue/strategies-re…
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psnet.ahrq.gov/node/43351/psn-pdf
July 16, 2014 - Patient involvement in medication safety in hospital: an
exploratory study.
July 16, 2014
Mohsin-Shaikh S, Garfield S, Franklin BD. Patient involvement in medication safety in hospital: an
exploratory study. Int J Clin Pharm. 2014;36(3):657-66. doi:10.1007/s11096-014-9951-8.
https://psnet.ahrq.gov/issue/patient-in…
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psnet.ahrq.gov/node/43540/psn-pdf
July 18, 2016 - Physicians' practice of dispensing medicines: a
qualitative study.
July 18, 2016
Darbyshire D, Gordon M, Baker P, et al. Physicians' Practice of Dispensing Medicines: A Qualitative Study.
J Patient Saf. 2016;12(2):82-8. doi:10.1097/PTS.0000000000000122.
https://psnet.ahrq.gov/issue/physicians-practice-dispensing-m…
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psnet.ahrq.gov/node/42591/psn-pdf
July 16, 2015 - Underreporting of robotic surgery complications.
July 16, 2015
Cooper M, Ibrahim AM, Lyu H, et al. Underreporting of robotic surgery complications. J Healthc Qual.
2015;37(2):133-8. doi:10.1111/jhq.12036.
https://psnet.ahrq.gov/issue/underreporting-robotic-surgery-complications
By cross-referencing court records a…
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psnet.ahrq.gov/node/39133/psn-pdf
August 15, 2018 - 2009 John M. Eisenberg Patient Safety and Quality
Awards.
August 15, 2018
Jt Comm J Qual Patient Saf. 2009;35(9):583-603.
https://psnet.ahrq.gov/issue/2009-john-m-eisenberg-patient-safety-and-quality-awards
This special issue highlights the efforts of the 2009 Eisenberg Award honorees and their impact on
improvin…