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psnet.ahrq.gov/node/47683/psn-pdf
April 10, 2019 - Design of hospital errors and omissions activities that
include patient-specific medication related problems.
April 10, 2019
Cooper JB, Bradley CL. Design of hospital errors and omissions activities that include patient-specific
medication related problems. Curr Pharm Teach Learn. 2019;11(1):66-75. doi:10.1016/j.cp…
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psnet.ahrq.gov/node/39164/psn-pdf
December 09, 2009 - Predictors of misunderstanding pediatric liquid
medication instructions.
December 9, 2009
Bailey SC, Pandit AU, Yin S, et al. Predictors of misunderstanding pediatric liquid medication instructions.
Fam Med. 2009;41(10):715-21.
https://psnet.ahrq.gov/issue/predictors-misunderstanding-pediatric-liquid-medication-in…
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psnet.ahrq.gov/node/61051/psn-pdf
October 21, 2020 - Safety investigations from across the pond: deep learning
from England’s Healthcare Safety Investigation Branch
(HSIB).
October 21, 2020
ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4
https://psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safe…
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psnet.ahrq.gov/node/45946/psn-pdf
July 02, 2017 - Multicompartment compliance aids in the community: the
prevalence of potentially inappropriate medications.
July 2, 2017
Counter D, Stewart D, MacLeod J, et al. Multicompartment compliance aids in the community: the
prevalence of potentially inappropriate medications. Br J Clin Pharmacol. 2017;83(7):1515-1520.
doi…
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psnet.ahrq.gov/node/45597/psn-pdf
December 14, 2016 - An E.R. kicks the habit of opioids for pain.
December 14, 2016
Hoffman J. New York Times. June 10, 2016.
https://psnet.ahrq.gov/issue/er-kicks-habit-opioids-pain
Overprescribing of opioids for pain management contributes to the growing crisis involving opioid-related
harm. This newspaper article reports on one hos…
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psnet.ahrq.gov/node/45806/psn-pdf
January 01, 2021 - Separate medication preparation rooms reduce
interruptions and medication errors in the hospital
setting: a prospective observational study.
February 15, 2017
Huckels-Baumgart S, Baumgart A, Buschmann U, et al. Separate Medication Preparation Rooms Reduce
Interruptions and Medication Errors in the Hospital Setting…
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/37906/psn-pdf
July 16, 2008 - Medication-related patient safety incidents in critical care:
a review of reports to the UK National Patient Safety
Agency.
July 16, 2008
Thomas AN, Panchagnula U. Medication-related patient safety incidents in critical care: a review of reports
to the UK National Patient Safety Agency. Anaesthesia. 2008;63(7):726…
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psnet.ahrq.gov/node/46292/psn-pdf
August 02, 2017 - Clinical alerts to decrease high-risk medication use in
older adults.
August 2, 2017
Lord-Adem W, Brandt NJ. Clinical Alerts to Decrease High-Risk Medication Use in Older Adults. J Gerontol
Nurs. 2017;43(7):7-12. doi:10.3928/00989134-20170614-04.
https://psnet.ahrq.gov/issue/clinical-alerts-decrease-high-risk-medi…
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psnet.ahrq.gov/node/60798/psn-pdf
January 01, 2021 - How accurately do older adult emergency department
patients recall their medications?
August 12, 2020
Goldberg EM, Marks SJ, Merchant RC, et al. How accurately do older adult emergency department
patients recall their medications? Acad Emerg Med. 2021;28(2):248-252. doi:10.1111/acem.14032.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/73995/psn-pdf
October 20, 2021 - Potential for medication overdose with ENFit low dose tip
syringe: FDA Safety Communication.
October 20, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.
https://psnet.ahrq.gov/issue/potential-medication-overdose-enfit-low-dose-tip-syringe-fda-safety-
communication
…
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psnet.ahrq.gov/node/42784/psn-pdf
January 15, 2014 - A multi-disciplinary approach to medication safety and
the implication for nursing education and practice.
January 15, 2014
Adhikari R, Tocher J, Smith P, et al. A multi-disciplinary approach to medication safety and the implication
for nursing education and practice. Nurse Educ Today. 2014;34(2):185-90. doi:10.101…
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psnet.ahrq.gov/node/43918/psn-pdf
September 27, 2017 - Medication-administration errors in an urban mental
health hospital: a direct observation study.
September 27, 2017
Cottney A, Innes J. Medication-administration errors in an urban mental health hospital: a direct
observation study. Int J Ment Health Nurs. 2015;24(1):65-74. doi:10.1111/inm.12096.
https://psnet.ahr…
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psnet.ahrq.gov/node/44076/psn-pdf
May 19, 2018 - The trigger tool as a method to measure harmful
medication errors in children.
May 19, 2018
Maaskant JM, Smeulers M, Bosman D, et al. The Trigger Tool as a Method to Measure Harmful Medication
Errors in Children. J Patient Saf. 2018;14(2):95-100. doi:10.1097/PTS.0000000000000177.
https://psnet.ahrq.gov/issue/trigg…
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psnet.ahrq.gov/node/44505/psn-pdf
January 22, 2016 - Reducing continuous intravenous medication errors in an
intensive care unit.
January 22, 2016
O?Byrne N, Kozub EI, Fields W. Reducing Continuous Intravenous Medication Errors in an Intensive Care
Unit. J Nurs Care Qual. 2016;31(1):13-16. doi:10.1097/NCQ.0000000000000144.
https://psnet.ahrq.gov/issue/reducing-conti…
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psnet.ahrq.gov/node/35112/psn-pdf
June 22, 2009 - Medication safety in older adults: home-based practice
patterns.
June 22, 2009
Metlay JP, Cohen A, Polsky D, et al. Medication safety in older adults: home-based practice patterns. J Am
Geriatr Soc. 2005;53(6):976-982.
https://psnet.ahrq.gov/issue/medication-safety-older-adults-home-based-practice-patterns
This s…
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/38839/psn-pdf
August 05, 2009 - Polypharmacy in hospitalized older adult cancer patients:
experience from a prospective, observational study of an
oncology-acute care for elders unit.
August 5, 2009
Flood KL, Carroll MB, Le C, et al. Polypharmacy in hospitalized older adult cancer patients: experience
from a prospective, observational study of…
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psnet.ahrq.gov/node/40476/psn-pdf
September 09, 2011 - Medication administration technologies and patient
safety: a mixed-method systematic review.
September 9, 2011
Wulff K, Cummings GG, Marck P, et al. Medication administration technologies and patient safety: a mixed-
method systematic review. J Adv Nurs. 2011;67(10):2080-95. doi:10.1111/j.1365-2648.2011.05676.x.
h…
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psnet.ahrq.gov/node/46906/psn-pdf
May 30, 2018 - Making an infusion error: the second victims of infusion
therapy-related medication errors.
May 30, 2018
Treiber LA, Jones JH. Making an Infusion Error: The Second Victims of Infusion Therapy-Related
Medication Errors. J Infus Nurs. 2018;41(3):156-163. doi:10.1097/NAN.0000000000000273.
https://psnet.ahrq.gov/issue…