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psnet.ahrq.gov/node/849613/psn-pdf
May 31, 2023 - Smart infusion pump investigations after an unexplained
over-infusion.
May 31, 2023
ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.
https://psnet.ahrq.gov/issue/smart-infusion-pump-investigations-after-unexplained-over-infusion
Dose error-reduction systems (DERS) and drug libraries are tool…
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psnet.ahrq.gov/node/844800/psn-pdf
September 25, 2019 - Patient Options for Safe and Effective Disposal of Unused
Opioids.
September 25, 2019
Washington, DC: United States Government Accountability Office; September 2019. Publication GAO-19-
650.
https://psnet.ahrq.gov/issue/patient-options-safe-and-effective-disposal-unused-opioids
One strategy to reduce the potentia…
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psnet.ahrq.gov/node/47517/psn-pdf
January 27, 2019 - Defining and classifying terminology for medication
harm: a call for consensus.
January 27, 2019
Falconer N, Barras M, Martin J, et al. Defining and classifying terminology for medication harm: a call for
consensus. Eur J Clin Pharmacol. 2019;75(2):137-145. doi:10.1007/s00228-018-2567-5.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/45764/psn-pdf
April 11, 2018 - Pediatric anesthesiology fellows' perception of quality of
attending supervision and medical errors.
April 11, 2018
Benzon HA, Hajduk J, De Oliveira GS, et al. Pediatric Anesthesiology Fellows' Perception of Quality of
Attending Supervision and Medical Errors. Anesth Analg. 2018;126(2):639-643.
doi:10.1213/ANE.000…
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psnet.ahrq.gov/node/47159/psn-pdf
August 01, 2018 - Safety II behavior in a pediatric intensive care unit.
August 1, 2018
Merandi J, Vannatta K, Davis T, et al. Safety II Behavior in a Pediatric Intensive Care Unit. Pediatrics.
2018;141(6):e20180018. doi:10.1542/peds.2018-0018.
https://psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit
The tradit…
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psnet.ahrq.gov/node/74693/psn-pdf
January 26, 2022 - Including the reason for use on prescriptions sent to
pharmacists: scoping review.
January 26, 2022
Mercer K, Carter C, Burns C, et al. Including the reason for use on prescriptions sent to pharmacists:
scoping review. JMIR Hum Factors. 2021;8(4):e22325. doi:10.2196/22325.
https://psnet.ahrq.gov/issue/including-re…
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psnet.ahrq.gov/node/47408/psn-pdf
September 19, 2018 - Ways to Improve Electronic Health Record Safety.
September 19, 2018
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety
Electronic health records both contribute to and detract from safe care. This…
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psnet.ahrq.gov/node/36032/psn-pdf
April 11, 2011 - Pediatric medication safety and the media: what does the
public see?
April 11, 2011
Stebbing C, Kaushal R, Bates DW. Pediatric medication safety and the media: what does the public see?
Pediatrics. 2006;117(6):1907-1914. doi:10.1542/peds.2005-2017.
https://psnet.ahrq.gov/issue/pediatric-medication-safety-and-media…
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psnet.ahrq.gov/node/42307/psn-pdf
January 14, 2014 - Comparison of intensive care unit medication errors
reported to the United States' MedMarx and the United
Kingdom's National Reporting and Learning System: a
cross-sectional study.
January 14, 2014
Wahr JA, Shore AD, Harris LH, et al. Comparison of intensive care unit medication errors reported to the
United Stat…
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psnet.ahrq.gov/node/34730/psn-pdf
October 29, 2013 - Medication Errors. 2nd ed.
October 29, 2013
Cohen MR, ed. Washington DC: American Pharmacists Association; 2007.
https://psnet.ahrq.gov/issue/medication-errors-2nd-ed
Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of
experience as a leader in medication safety wi…
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psnet.ahrq.gov/node/45846/psn-pdf
January 07, 2019 - Medication safety in the operating room: literature and
expert-based recommendations.
January 7, 2019
Wahr JA, Abernathy JH, Lazarra EH, et al. Medication safety in the operating room: literature and expert-
based recommendations. Br J Anaesth. 2017;118(1):32-43. doi:10.1093/bja/aew379.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/851194/psn-pdf
July 05, 2023 - The additional cost of perioperative medication errors
July 5, 2023
Langlieb ME, Sharma P, Hocevar M, et al. The additional cost of perioperative medication errors. J Patient
Saf. 2023;19(6):375-378. doi:10.1097/pts.0000000000001136.
https://psnet.ahrq.gov/issue/additional-cost-perioperative-medication-errors
Prev…
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psnet.ahrq.gov/node/43119/psn-pdf
April 16, 2014 - Still outside the bull's eye: 2014–2015 Targeted
Medication Safety Best Practices.
April 16, 2014
ISMP Medication Safety Alert! Acute care edition. March 27, 2014;19:1-5.
https://psnet.ahrq.gov/issue/still-outside-bulls-eye-2014-2015-targeted-medication-safety-best-practices
This newsletter article reports results…
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psnet.ahrq.gov/node/45896/psn-pdf
March 15, 2017 - Medication governance: preventing errors and promoting
patient safety.
March 15, 2017
Kavanagh C. Medication governance: preventing errors and promoting patient safety. Br J Nurs.
2017;26(3):159-165. doi:10.12968/bjon.2017.26.3.159.
https://psnet.ahrq.gov/issue/medication-governance-preventing-errors-and-promoting…
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psnet.ahrq.gov/node/47653/psn-pdf
January 16, 2019 - Exploring pharmacist experiences of delivering
individualised prescribing error feedback in an acute
hospital setting.
January 16, 2019
Lloyd M, Watmough SD, O'Brien S, et al. Exploring pharmacist experiences of delivering individualised
prescribing error feedback in an acute hospital setting. Res Social Adm Pharm…
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psnet.ahrq.gov/node/837040/psn-pdf
May 04, 2022 - Use duodenoscopes with innovative designs to enhance
safety: FDA Safety Communication.
May 4, 2022
Silver Spring, MD: US Food and Drug Administration; April 5, 2022.
https://psnet.ahrq.gov/issue/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-
communication
The challenge of medical device steriliza…
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psnet.ahrq.gov/node/41899/psn-pdf
December 05, 2012 - National and local medication error reporting systems—a
survey of practices in 16 countries.
December 5, 2012
Holmström A-R, Airaksinen M, Weiss M, et al. National and local medication error reporting systems: a
survey of practices in 16 countries. J Patient Saf. 2012;8(4):165-76. doi:10.1097/PTS.0b013e3182676cf3.
…
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psnet.ahrq.gov/node/61126/psn-pdf
November 11, 2020 - Potential for false positive results with antigen tests for
rapid detection of SARS-CoV-2--letter to clinical
laboratory staff and health care providers.
November 11, 2020
US Food and Drug Administration: November 3, 2020.
https://psnet.ahrq.gov/issue/potential-false-positive-results-antigen-tests-rapid-detection-…
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psnet.ahrq.gov/node/43791/psn-pdf
December 17, 2014 - Facilitating Patient Understanding of Discharge
Instructions: Workshop Summary.
December 17, 2014
Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN:
9780309307383.
https:…
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psnet.ahrq.gov/node/73969/psn-pdf
October 26, 2021 - Important Actions Community Pharmacists Need to Take
Now to Reduce Potentially Harmful Dispensing Errors.
October 13, 2021
Institute for Safe Medication Practices. October 26, 2021.
https://psnet.ahrq.gov/issue/important-actions-community-pharmacists-need-take-now-reduce-potentially-
harmful-dispensing
Community …