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psnet.ahrq.gov/issue/legality-technicians-involvement-medication-reconciliation-not-clear
June 13, 2011 - Newspaper/Magazine Article
Legality of technicians' involvement in medication reconciliation not clear.
Citation Text:
Thompson CA. Legality of technicians' involvement in medication reconciliation not clear. American journal of health-system pharmacy : AJHP : official journal of the A…
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psnet.ahrq.gov/issue/winning-battle-standardization
March 02, 2022 - Newspaper/Magazine Article
Winning the battle for standardization.
Citation Text:
Durkee RP, Richard LW. Winning the battle for standardization. The U.S. Army Medical Department examines the EMR to develop a standardized process for medication reconciliation documentation. Health Manag…
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psnet.ahrq.gov/issue/novel-tool-organisational-learning-and-its-impact-safety-culture-hospital-dispensary
January 21, 2015 - Study
A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.
Citation Text:
Sujan MA. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. Reliab Eng Syst Saf. 2012;101:21-34. doi:10.1016/j.ress…
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psnet.ahrq.gov/issue/benefits-direct-observation-medication-administration-detect-errors
March 09, 2022 - Study
Benefits of direct observation in medication administration to detect errors.
Citation Text:
Diaz-Navarlaz T, Pronovost P, Beortegui E, et al. Benefits of Direct Observation in Medication Administration to Detect Errors. J Patient Saf. 2009;3(4). doi:10.1097/pts.0b013e31815b4cc3.…
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psnet.ahrq.gov/issue/medication-reconciliation-acute-care-ensuring-accurate-drug-regimen-admission-and-discharge
October 28, 2020 - Commentary
Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.
Citation Text:
Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Jt Comm J Qual Patient Saf. 2005…
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psnet.ahrq.gov/issue/potentially-inappropriate-medications-and-adverse-drug-effects-elders-ed
December 23, 2020 - Study
Potentially inappropriate medications and adverse drug effects in elders in the ED.
Citation Text:
Nixdorff N, Hustey FM, Brady AK, et al. Potentially inappropriate medications and adverse drug effects in elders in the ED. Am J Emerg Med. 2008;26(6):697-700. doi:10.1016/j.ajem.20…
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psnet.ahrq.gov/issue/labeling-morphine-milligram-equivalents-opioid-packaging-potential-patient-safety
March 06, 2019 - Review
Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention.
Citation Text:
Stone AB, Urman RD, Kaye AD, et al. Labeling Morphine Milligram Equivalents on Opioid Packaging: a Potential Patient Safety Intervention. Curr Pain Headache Rep. 20…
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psnet.ahrq.gov/issue/case-improving-measurement-intraoperative-iatrogenic-injuries
February 14, 2017 - Commentary
A case for improving measurement of intraoperative iatrogenic injuries.
Citation Text:
Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries. JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237.
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - Relationships Between Physician Professional Satisfaction and Patient Safety
Mark Friedberg, MD, MPP | February 1, 2016
View more articles from the same authors.
Citation Text:
Friedberg MW. Relationships Between Physician Professional Satisfaction and Patient Saf…
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/node/49467/psn-pdf
December 01, 2004 - A "Weak" Response
December 1, 2004
Reisman AB. A "Weak" Response. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/weak-response
The Case
A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said,
"They started me on a new pill for my blood pressure and now I fe…
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psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - Annual Perspective
Burnout Among Health Professionals and Its Effect on Patient Safety
Audrey Lyndon, PhD | January 1, 2015
View more articles from the same authors.
Citation Text:
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety…
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Patient Allergies and Electronic Health Records
Citation Text:
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …