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psnet.ahrq.gov/node/34977/psn-pdf
April 21, 2010 - Effectiveness of a computerized system for intravenous
heparin administration: using information technology to
improve patient care and patient safety.
April 21, 2010
Oyen LJ, Nishimura RA, Ou NN, et al. Effectiveness of a computerized system for intravenous heparin
administration: using information technology to …
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psnet.ahrq.gov/node/42020/psn-pdf
July 16, 2013 - Effects of the implementation of a preventive
interventions program on the reduction of medication
errors in critically ill adult patients.
July 16, 2013
Romero CM, Salazar N, Rojas L, et al. Effects of the implementation of a preventive interventions program
on the reduction of medication errors in critically ill…
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psnet.ahrq.gov/node/47784/psn-pdf
February 13, 2019 - Patterns in outpatient benzodiazepine prescribing in the
United States.
February 13, 2019
Agarwal SD, Landon BE. Patterns in Outpatient Benzodiazepine Prescribing in the United States. JAMA
Netw Open. 2019;2(1):e187399. doi:10.1001/jamanetworkopen.2018.7399.
https://psnet.ahrq.gov/issue/patterns-outpatient-benzodi…
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psnet.ahrq.gov/node/45370/psn-pdf
July 27, 2016 - Correct use of inhalers: help patients breathe easier.
July 27, 2016
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
https://psnet.ahrq.gov/issue/correct-use-inhalers-help-patients-breathe-easier
Patients and clinicians can make medication administration mistakes when new drug delivery mecha…
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psnet.ahrq.gov/node/40808/psn-pdf
January 12, 2012 - Prevalence of polypharmacy exposure among
hospitalized children in the United States.
January 12, 2012
Feudtner C, Dai D, Hexem KR, et al. Prevalence of polypharmacy exposure among hospitalized children in
the United States. Arch Pediatr Adolesc Med. 2012;166(1):9-16. doi:10.1001/archpediatrics.2011.161.
https://p…
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psnet.ahrq.gov/node/48090/psn-pdf
August 28, 2019 - Preventing errors with high-risk medications.
August 28, 2019
Wiley F. Drug Topics. August 2019;1633:16-18.
https://psnet.ahrq.gov/issue/preventing-errors-high-risk-medications
High-alert medications have the potential to cause serious patient harm if not administered correctly.
Reporting on challenges to medicati…
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psnet.ahrq.gov/node/35697/psn-pdf
July 12, 2010 - An overview of intravenous-related medication
administration errors as reported to MEDMARX(R), a
national medication error-reporting program.
July 12, 2010
Hicks RW, Becker SC. An overview of intravenous-related medication administration errors as reported to
MEDMARX, a national medication error-reporting program.…
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psnet.ahrq.gov/node/42018/psn-pdf
February 27, 2013 - Scale, nature, preventability and causes of adverse
events in hospitalised older patients.
February 27, 2013
Merten H, Zegers M, de Bruijne M, et al. Scale, nature, preventability and causes of adverse events in
hospitalised older patients. Age Ageing. 2013;42(1):87-93. doi:10.1093/ageing/afs153.
https://psnet.ahr…
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psnet.ahrq.gov/node/34668/psn-pdf
June 06, 2018 - Please don't sleep through this wake-up call.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.
https://psnet.ahrq.gov/issue/please-dont-sleep-through-wake-call
This is an alert from the Institute for Safe Medication Practices informing readers of a fatal medication error
that occu…
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psnet.ahrq.gov/node/37338/psn-pdf
January 02, 2017 - Using the rapid response system to provide better
oversight of patient care processes.
January 2, 2017
Moore MS, Howard SK, Lighthall GK. Using the rapid response system to provide better oversight of
patient care processes. Jt Comm J Qual Patient Saf. 2007;33(11):695-8, 645.
https://psnet.ahrq.gov/issue/using-rap…
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psnet.ahrq.gov/node/73101/psn-pdf
April 07, 2021 - Do No Harm: Are We Preventing Medication Errors in
Children with Medical Complexity?
March 31, 2021
Children's Healthcare Canada. April 7, 2021.
https://psnet.ahrq.gov/issue/do-no-harm-are-we-preventing-medication-errors-children-medical-complexity
Children are particularly vulnerable to medication errors. This se…
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psnet.ahrq.gov/node/46687/psn-pdf
February 21, 2018 - Oversedation of a patient with obstructive sleep apnea
prior to imaging.
February 21, 2018
Blay E, Barnard C, Bilimoria KY. Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging.
JAMA. 2018;319(5):495-496. doi:10.1001/jama.2017.22004.
https://psnet.ahrq.gov/issue/oversedation-patient-obstructive-…
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psnet.ahrq.gov/node/41896/psn-pdf
December 12, 2012 - Bar-code verification: reducing but not eliminating
medication errors.
December 12, 2012
Henneman PL, Marquard J, Fisher DL, et al. Bar-code verification: reducing but not eliminating medication
errors. J Nurs Adm. 2012;42(12):562-6. doi:10.1097/NNA.0b013e318274b545.
https://psnet.ahrq.gov/issue/bar-code-verificat…
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psnet.ahrq.gov/node/38791/psn-pdf
September 08, 2010 - Dispensing errors and counseling quality in 100
pharmacies.
September 8, 2010
Flynn EA, Barker KN, Berger BA, et al. Dispensing errors and counseling quality in 100 pharmacies. J Am
Pharm Assoc (2003). 2009;49(2):171-80. doi:10.1331/JAPhA.2009.08130.
https://psnet.ahrq.gov/issue/dispensing-errors-and-counseling-qu…
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psnet.ahrq.gov/node/41827/psn-pdf
November 21, 2012 - Dementia and risk of adverse warfarin-related events in
the nursing home setting.
November 21, 2012
Tjia J, Field T, Mazor KM, et al. Dementia and risk of adverse warfarin-related events in the nursing home
setting. Am J Geriatr Pharmacother. 2012;10(5):323-30. doi:10.1016/j.amjopharm.2012.09.003.
https://psnet.ah…
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psnet.ahrq.gov/node/40507/psn-pdf
June 08, 2011 - From research to practice: factors affecting
implementation of prospective targeted injury-detection
systems.
June 8, 2011
Sorensen A, Harrison MI, Kane HL, et al. From research to practice: factors affecting implementation of
prospective targeted injury-detection systems. BMJ Qual Saf. 2011;20(6):527-33.
doi:10.…
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psnet.ahrq.gov/node/36026/psn-pdf
March 28, 2011 - Inter- and intra-rater reliability for classification of
medication related events in paediatric inpatients.
March 28, 2011
Kunac DL, Reith DM, Kennedy J, et al. Inter- and intra-rater reliability for classification of medication related
events in paediatric inpatients. Qual Saf Health Care. 2006;15(3):196-201.
ht…
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psnet.ahrq.gov/node/41503/psn-pdf
January 18, 2013 - Medication safety in primary care practice: results from a
PPRNet quality improvement intervention.
January 18, 2013
Wessell AM, Ornstein SM, Jenkins RG, et al. Medication Safety in Primary Care Practice: results from a
PPRNet quality improvement intervention. Am J Med Qual. 2013;28(1):16-24.
doi:10.1177/106286061…
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psnet.ahrq.gov/node/39881/psn-pdf
November 02, 2010 - Automated detection of harm in healthcare with
information technology: a systematic review.
November 2, 2010
Govindan M, Van Citters AD, Nelson EC, et al. Automated detection of harm in healthcare with information
technology: a systematic review. Qual Saf Health Care. 2010;19(5):e11. doi:10.1136/qshc.2009.033027.
…
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psnet.ahrq.gov/node/45467/psn-pdf
September 14, 2016 - Three simple rules to improve medication safety.
September 14, 2016
Barba V. Three Simple Rules to Improve Medication Safety. J Patient Saf. 2016;12(3):171-2.
doi:10.1097/PTS.0000000000000095.
https://psnet.ahrq.gov/issue/three-simple-rules-improve-medication-safety
Safety improvement strategies can range in diffi…