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psnet.ahrq.gov/node/44093/psn-pdf
April 29, 2015 - South Carolina medication error bill is dangerously off
target.
April 29, 2015
ISMP Medication Safety Alert! Acute Care Edition. April 9, 2015;20:1,4.
https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target
This newsletter article reports on issues related to a legislation, drafted in …
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
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psnet.ahrq.gov/node/42991/psn-pdf
March 12, 2014 - Medication errors in hospitalised children.
March 12, 2014
Manias E, Kinney S, Cranswick N, et al. Medication errors in hospitalised children. J Paediatr Child Health.
2014;50(1):71-7. doi:10.1111/jpc.12412.
https://psnet.ahrq.gov/issue/medication-errors-hospitalised-children
Consistent with findings from prior st…
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psnet.ahrq.gov/node/46688/psn-pdf
January 01, 2018 - New solutions to reduce wrong route medication errors.
December 18, 2017
Litman RS, Smith VI, Mainland P. New solutions to reduce wrong route medication errors. Paediatr
Anaesth. 2018;28(1):8-12. doi:10.1111/pan.13279.
https://psnet.ahrq.gov/issue/new-solutions-reduce-wrong-route-medication-errors
Tubing misconnec…
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psnet.ahrq.gov/node/43066/psn-pdf
December 10, 2014 - Reminder: pay attention to the appearance of your
medicines.
December 10, 2014
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
This newsletter article describes an incident involving a patient who noticed that the tabl…
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psnet.ahrq.gov/node/50383/psn-pdf
September 25, 2019 - Epidemiology of adverse events and medical errors in the
care of cardiology patients.
September 25, 2019
Ohta Y, Miki I, Kimura T, et al. Epidemiology of Adverse Events and Medical Errors in the Care of
Cardiology Patients. J Patient Saf. 2019;15(3):251-256. doi:10.1097/PTS.0000000000000291.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/41633/psn-pdf
January 01, 2013 - Determinants of success of quality improvement
collaboratives: what does the literature show?
December 31, 2012
Hulscher M, Schouten LMT, Grol R, et al. Determinants of success of quality improvement collaboratives:
what does the literature show? BMJ Qual Saf. 2013;22(1):19-31. doi:10.1136/bmjqs-2011-000651.
https…
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psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
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psnet.ahrq.gov/node/46854/psn-pdf
June 20, 2018 - FDA Safety Communication: recommendations to reduce
surgical fires and related patient injury.
June 20, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018.
https://psnet.ahrq.gov/issue/fda-safety-communication-recommendations-reduce-surgical-fires-and-related-
patient-inju…
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psnet.ahrq.gov/node/44729/psn-pdf
January 07, 2016 - The morbidity and mortality meeting: time for a different
approach?
January 7, 2016
Fraser J. The morbidity and mortality meeting: time for a different approach? Arch Dis Child. 2016;101(1):4-
8. doi:10.1136/archdischild-2015-309536.
https://psnet.ahrq.gov/issue/morbidity-and-mortality-meeting-time-different-appro…
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www.ahrq.gov/evidencenow/heart-health/smoking/treatment.html
August 01, 2018 - Treating Tobacco Use and Dependence: 2008 Update by HHS Panel
Resource title: Treating Tobacco Use and Dependence: 2008 Update
Resource description: This update to a previous guideline by the Tobacco Use and Dependence Guideline Panel contains strategies and recommendations for effective treatments for tob…
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integrationacademy.ahrq.gov/sites/default/files/2021-10/Rack_Card_10.25.11.pdf
January 01, 2021 - Integrated Care: Physical & Emotional Heath (Rack card)
Integrated Care: Physical & Emotional Health
Are you struggling
with an emotional issue
and not sure how
to get help?
We’re here for you.
Integrated Care: Physical & Emotional Health
Integrated Care combines car…
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psnet.ahrq.gov/node/41776/psn-pdf
January 30, 2013 - Comparison of traditional trigger tool to data warehouse
based screening for identifying hospital adverse events.
January 30, 2013
O'Leary KJ, Devisetty VK, Patel AR, et al. Comparison of traditional trigger tool to data warehouse based
screening for identifying hospital adverse events. BMJ Qual Saf. 2013;22(2):130…
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psnet.ahrq.gov/node/42544/psn-pdf
December 18, 2013 - Communicating medication changes to community
pharmacy post-discharge: the good, the bad, and the
improvements.
December 18, 2013
Urban R, Paloumpi E, Rana N, et al. Communicating medication changes to community pharmacy post-
discharge: the good, the bad, and the improvements. Int J Clin Pharm. 2013;35(5):813-20.…
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psnet.ahrq.gov/node/837703/psn-pdf
July 20, 2022 - Family safety reporting in hospitalized children with
medical complexity.
July 20, 2022
Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical
complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098.
https://psnet.ahrq.gov/issue/family-safety-repo…
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psnet.ahrq.gov/node/41928/psn-pdf
January 30, 2013 - Perceived causes of prescribing errors by junior doctors
in hospital inpatients: a study from the PROTECT
programme.
January 30, 2013
Ross S, Ryan C, Duncan EM, et al. Perceived causes of prescribing errors by junior doctors in hospital
inpatients: a study from the PROTECT programme. BMJ Qual Saf. 2013;22(2):97-10…
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-graphic-2014.pdf
January 01, 2014 - Patients Safer as Hospital-Acquired Conditions Decline (Data Graphic)
REDUCTION
IN HACs
REDUCTION
IN HACs
17%17%
LIVES SAVEDLIVES SAVED
87,00087,000
$$$
IN COSTS AVERTEDIN COSTS AVERTED
$19.8
BILLION
$19.8
BILLION
INSTANCES OF
HACs AVOIDED
INSTANCES OF
HACs AVOIDED
2.1
MILLION
2.1
MILLION
From 2010–2014, 1…
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - addition, the commentary does not include
information regarding investigational or off-label use of pharmaceutical … products or medical devices.
-
www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
January 01, 2024 - use
process; 85%, by type of error; 50%, by cause of error; and 20%, by therapeutic class of the
drugs … 22
Phase (node) of medication use process in which error
originated
11
Cause of the error 14
Drugs … double check opioids prior to administration 0 7 9 3 1 2 0 5
Written policy to double check chemotherapy drugs
-
www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
November 01, 2017 - Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions
FINAL REPORT
Estimating the Additional Hospital Inpatient
Cost and Mortality Associated With
Selected Hospital-Acquired Conditions
PREPARED FOR:
Agency for Healthcare Resear…