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  1. Improvement of medication event interventions through use of an electronic database. | PSNet

    psnet.ahrq.gov/issue/improvement-medication-event-interventions-through-use-electronic-database
    December 19, 2014 - Study Improvement of medication event interventions through use of an electronic database. Citation Text: Merandi J, Morvay S, Lewe D, et al. Improvement of medication event interventions through use of an electronic database. Am J Health Syst Pharm. 2013;70(19):1708-14. doi:10.2146/ajh…

  2. The costs of adverse drug events in community hospitals. | PSNet

    psnet.ahrq.gov/issue/costs-adverse-drug-events-community-hospitals
    February 18, 2011 - Study The costs of adverse drug events in community hospitals. Citation Text: Hug BL, Keohane C, Seger DL, et al. The costs of adverse drug events in community hospitals. Jt Comm J Qual Patient Saf. 2012;38(3):120-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNot…

  3. Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting. | PSNet

    psnet.ahrq.gov/issue/associations-between-communication-climate-and-frequency-medical-error-reporting-among
    July 18, 2016 - Study Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting. Citation Text: Patterson ME, Pace HA, Fincham JE. Associations between communication climate and the frequency of medical error reporting among ph…

  4. Clinical relevance of and risk factors associated with medication administration time errors. | PSNet

    psnet.ahrq.gov/issue/clinical-relevance-and-risk-factors-associated-medication-administration-time-errors
    May 08, 2017 - Study Clinical relevance of and risk factors associated with medication administration time errors. Citation Text: Teunissen R, Bos J, Pot H, et al. Clinical relevance of and risk factors associated with medication administration time errors. Am J Health Syst Pharm. 2013;70(12):1052-6. …

  5. Every error a treasure: improving medication use with a nonpunitive reporting system. | PSNet

    psnet.ahrq.gov/issue/every-error-treasure-improving-medication-use-nonpunitive-reporting-system
    August 17, 2016 - Study Every error a treasure: improving medication use with a nonpunitive reporting system. Citation Text: Lehmann DF, Page N, Kirschman K, et al. Every Error a Treasure: Improving Medication Use with a Nonpunitive Reporting System. Jt Comm J Qual Patient Saf. 2016;33(7):401-407. doi:10.…

  6. Increase in US medication-error deaths between 1983 and 1993. | PSNet

    psnet.ahrq.gov/issue/increase-us-medication-error-deaths-between-1983-and-1993
    March 14, 2022 - Study Classic Increase in US medication-error deaths between 1983 and 1993. Citation Text: Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351(9103):643-4. Copy Citation Format: Go…

  7. Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. | PSNet

    psnet.ahrq.gov/issue/prescribing-errors-admission-hospital-and-their-potential-impact-mixed-methods-study
    December 20, 2023 - Study Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. Citation Text: Basey AJ, Krska J, Kennedy TD, et al. Prescribing errors on admission to hospital and their potential impact: a mixed-methods study. BMJ Qual Saf. 2014;23(1):17-25. doi:1…

  8. Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors. | PSNet

    psnet.ahrq.gov/issue/utilization-seniors-falls-investigation-methodology-identify-system-wide-causes-falls
    November 21, 2014 - Study Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors. Citation Text: Zecevic AA, Salmoni AW, Lewko JH, et al. Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of f…

  9. A scoping review of the hidden curriculum in pharmacy education. | PSNet

    psnet.ahrq.gov/issue/scoping-review-hidden-curriculum-pharmacy-education
    November 16, 2022 - Review A scoping review of the hidden curriculum in pharmacy education. Citation Text: Park SK, Chen AMH, Daugherty KK, et al. A scoping review of the hidden curriculum in pharmacy education. Am J Pharm Educ. 2023;87(3):ajpe8999. doi:10.5688/ajpe8999. Copy Citation Format: …

  10. Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge. | PSNet

    psnet.ahrq.gov/issue/prospective-risk-analysis-and-incident-reporting-better-pharmaceutical-care-paediatric
    June 27, 2011 - Study Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge. Citation Text: Kaestli L-Z, Cingria L, Fonzo-Christe C, et al. Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital di…

  11. Inter-rater reliability of a classification system for hospital adverse drug event reports. | PSNet

    psnet.ahrq.gov/issue/inter-rater-reliability-classification-system-hospital-adverse-drug-event-reports
    March 30, 2011 - Study Inter-rater reliability of a classification system for hospital adverse drug event reports. Citation Text: Haynes K, Hennessy S, Morales KH, et al. Inter-rater reliability of a classification system for hospital adverse drug event reports. Clin Pharmacol Ther. 2008;83(3):485-8. …

  12. Missed diagnoses of acute cardiac ischemia in the emergency department. | PSNet

    psnet.ahrq.gov/issue/missed-diagnoses-acute-cardiac-ischemia-emergency-department
    November 30, 2012 - Study Classic Missed diagnoses of acute cardiac ischemia in the emergency department. Citation Text: Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163-1170. doi:10.…

  13. Epidemiology, comparative methods of detection, and preventability of adverse drug events. | PSNet

    psnet.ahrq.gov/issue/epidemiology-comparative-methods-detection-and-preventability-adverse-drug-events
    March 09, 2016 - Study Epidemiology, comparative methods of detection, and preventability of adverse drug events. Citation Text: Al-Tajir GK, Kelly WN. Epidemiology, comparative methods of detection, and preventability of adverse drug events. Ann Pharmacother. 2005;39(7-8):1169-74. Copy Citation …

  14. Diagnostic delays in infectious diseases. | PSNet

    psnet.ahrq.gov/issue/diagnostic-delays-infectious-diseases
    December 15, 2021 - Study Diagnostic delays in infectious diseases. Citation Text: Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnostic delays in infectious diseases. Diagnosis (Berl). 2022;9(3):332-339. doi:10.1515/dx-2021-0092. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML E…

  15. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - time period for ascertainment.11,14,17,18 – The most common complications are wound problems such as infection … wall or gastric wall ulceration,6,11,14 tube dislodgement with peritonitis or necrotizing soft tissue infection … sedation or specialized equipment. – When the PEG tube has complications, such as a skin or soft tissue infection

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60044/psn-pdf
    March 16, 2020 - Specific consideration for infection prevention and control practices. … competencies include those that focus on: Improving individual safety practices, such as practicing infection-control

  17. After-Visit Confusion | PSNet

    psnet.ahrq.gov/web-mm/after-visit-confusion
    August 21, 2007 - The symptoms developed a few days following an upper respiratory infection. … Ultimately, the physician spoke with the patient's mother, confirmed that his diagnosis of a herpetic viral infection

  18. Maternal Safety | PSNet

    psnet.ahrq.gov/primer/maternal-safety
    January 10, 2024 - An example of this is the risk for infection , hemorrhage , future cesarean birth, and future potentially … Maternal sepsis is defined as a life-threatening condition with organ dysfunction resulting from infection … sepsis related. 29 The AIM Sepsis in Obstetrical Care toolkit includes similar bundles and focuses on infection

  19. Missed Nursing Care: A Key Measure for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
    March 01, 2018 - One example would be care bundles for central line infection prevention. … And these differences line up very closely to the variation across hospitals in mortality, infection … Readmissions, infection rates, never events like poor glycemic control—they're all directly related to

  20. In Conversation With… Kaveh Shojania, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - So you have surgical problems, medication problems, diagnostic problems, infections, and so on. … If you've implemented the central line bundle, then you should measure central line–associated infections
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