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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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. …
  18. Psn-Pdf (pdf file)

    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-…
  19. Psn-Pdf (pdf file)

    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:…
  20. Psn-Pdf (pdf file)

    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 …