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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39974/psn-pdf
    June 27, 2011 - How are medication errors defined? A systematic literature review of definitions and characteristics. June 27, 2011 Lisby M, Nielsen LP, Brock B, et al. How are medication errors defined? A systematic literature review of definitions and characteristics. International Journal for Quality in Health Care. 2010;22(6).…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45986/psn-pdf
    March 29, 2017 - Pediatric prehospital medication dosing errors: a national survey of paramedics. March 29, 2017 Hoyle JD, Crowe RP, Bentley MA, et al. Pediatric prehospital medication dosing errors: a national survey of paramedics. Prehosp Emerg Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001. https://psnet.ahrq.gov/i…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42380/psn-pdf
    December 29, 2014 - Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis. December 29, 2014 Coleman JJ, Hodson J, Brooks HL, et al. Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysi…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35286/psn-pdf
    February 24, 2011 - Outpatient prescribing errors and the impact of computerized prescribing. February 24, 2011 Gandhi TK, Weingart SN, Seger AC, et al. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med. 2005;20(9):837-841. doi:10.1111/j.1525-1497.2005.0194.x. https://psnet.ahrq.gov/issue/outp…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35766/psn-pdf
    March 02, 2011 - Unexpected hypoglycemia in a critically ill patient. March 2, 2011 Bates DW. Unexpected hypoglycemia in a critically ill patient. Ann Intern Med. 2002;137(2):110-6. https://psnet.ahrq.gov/issue/unexpected-hypoglycemia-critically-ill-patient This case study shares the experiences of a patient who suffered a medicati…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47028/psn-pdf
    May 02, 2018 - Medication errors 2018: the year in review. May 2, 2018 Valentine D, Ingram V, Fobi BNN, Brahmbhatt V. Pharmacy Practice News. April 4, 2018. https://psnet.ahrq.gov/issue/medication-errors-2018-year-review Despite considerable effort, medication errors continue to occur and result in patient harm. Summari…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851196/psn-pdf
    July 05, 2023 - Patient falls while under supervision: trends from incident reporting. July 5, 2023 Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs. 2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508. https://psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42643/psn-pdf
    October 09, 2013 - FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety?emphasizing that accidental exposure to used patches can cause death. October 9, 2013 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 23, 2013. https://psnet.ahrq.gov/issue/fda-requiring-color-change…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34697/psn-pdf
    December 08, 2010 - Sentinel events. In memory of Ben—a case study. December 8, 2010 Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5. https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study Written from the perspective of a risk manager, the author tells the story of a medication a…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42896/psn-pdf
    February 23, 2015 - Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists. February 23, 2015 Gilbar P, Chambers C, Larizza M. Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists. J Oncol Pharm Pract. 2015;21(1):10-…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73498/psn-pdf
    July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850360/psn-pdf
    June 14, 2023 - Taking a closer look at medication errors that involve oxytocin. June 14, 2023 ISMP Medication Safety Alert! Acute care edition. June 1, 2023; 28(11):1-6. https://psnet.ahrq.gov/issue/taking-closer-look-medication-errors-involve-oxytocin Oxytocin, which is commonly used to induce labor, has been associated with ad…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74763/psn-pdf
    June 25, 2021 - FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. June 25, 2021 Silver Springs, MD: US Food and Drug Administration: June 25, 2021. https://psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated- recommendations-reprocessing Incomplete reproce…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45547/psn-pdf
    October 05, 2016 - Sick children face potentially deadly danger: medication errors. October 5, 2016 Furfaro H. Wall Street Journal. September 25, 2016. https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors Medication errors in pediatric care are common in the hospital and at home. This newspaper…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36242/psn-pdf
    March 06, 2019 - Your attention please... designing effective warnings. March 6, 2019 ISMP Medication Safety Alert! Acute care edition. February 28, 2019. https://psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings Medication warnings inform providers and patients about risks associated with medication use. As w…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45387/psn-pdf
    August 15, 2016 - Preventing medication errors. August 15, 2016 Stefanacci RG, Riddle A. Preventing medication errors. Geriatr Nurs. 2016;37(4):307-10. doi:10.1016/j.gerinurse.2016.06.005. https://psnet.ahrq.gov/issue/preventing-medication-errors Nursing home patients are particularly vulnerable to medication errors. This commentar…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39051/psn-pdf
    November 04, 2009 - On the prospects for a blame-free medical culture. November 4, 2009 Collins ME, Block SD, Arnold RM, et al. On the prospects for a blame-free medical culture. Soc Sci Med. 2009;69(9):1287-90. doi:10.1016/j.socscimed.2009.08.033. https://psnet.ahrq.gov/issue/prospects-blame-free-medical-culture This study found tha…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44401/psn-pdf
    November 20, 2015 - Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. November 20, 2015 Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A, et al. Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. Int J Clin Prac…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41273/psn-pdf
    June 01, 2012 - Minimizing inappropriate medications in older populations: a ten-step conceptual framework. June 1, 2012 Scott IA, Gray LC, Martin J, et al. Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med. 2012;125(6):529-37.e4. doi:10.1016/j.amjmed.2011.09.021. https://psnet.ah…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45273/psn-pdf
    October 13, 2018 - Using an inpatient portal to engage families in pediatric hospital care. October 13, 2018 Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070. https://psnet.ahrq.gov/issue/using-inpatient-portal…
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