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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - implementation of the corrective actions is often incomplete; and, at the end of the RCA process (which often involves
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - Joint Commission and the VA Medication Reconciliation Initiative, effective medication reconciliation involves
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - The Commentary This error involves a system failure in the proper identification, documentation, and
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - One system involves Therapeutic Antibiotic Monitoring (TAM) alerts in which coordinated pharmacy and
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psnet.ahrq.gov/node/36744/psn-pdf
August 02, 2011 - Nurses relate the contributing factors involved in
medication errors.
August 2, 2011
Tang F-I, Sheu S-J, Yu S, et al. Nurses relate the contributing factors involved in medication errors. J Clin
Nurs. 2007;16(3):447-57.
https://psnet.ahrq.gov/issue/nurses-relate-contributing-factors-involved-medication-errors
The…
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psnet.ahrq.gov/node/41137/psn-pdf
May 04, 2012 - Predictors of prescription errors involving anticancer
chemotherapy agents.
May 4, 2012
Ranchon F, Moch C, You B, et al. Predictors of prescription errors involving anticancer chemotherapy
agents. Eur J Cancer. 2012;48(8):1192-9. doi:10.1016/j.ejca.2011.12.031.
https://psnet.ahrq.gov/issue/predictors-prescription-…
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psnet.ahrq.gov/node/43351/psn-pdf
July 16, 2014 - Patient involvement in medication safety in hospital: an
exploratory study.
July 16, 2014
Mohsin-Shaikh S, Garfield S, Franklin BD. Patient involvement in medication safety in hospital: an
exploratory study. Int J Clin Pharm. 2014;36(3):657-66. doi:10.1007/s11096-014-9951-8.
https://psnet.ahrq.gov/issue/patient-in…
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psnet.ahrq.gov/node/44269/psn-pdf
July 01, 2015 - Accidental overdoses involving fluorouracil infusions.
July 1, 2015
ISMP Medication Safety Alert! Acute Care Edition. June 18, 2015;20:1:5.
https://psnet.ahrq.gov/issue/accidental-overdoses-involving-fluorouracil-infusions
Describing three accidental overdoses of the antineoplastic drug fluorouracil which involved …
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psnet.ahrq.gov/node/45511/psn-pdf
July 21, 2017 - Can patient involvement improve patient safety? A cluster
randomised control trial of the Patient Reporting and
Action for a Safe Environment (PRASE) intervention.
July 21, 2017
Lawton R, O'Hara JK, Sheard L, et al. Can patient involvement improve patient safety? A cluster
randomised control trial of the Patient R…
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psnet.ahrq.gov/node/40289/psn-pdf
March 16, 2011 - Unintentional therapeutic errors involving insulin in the
ambulatory setting reported to poison centers.
March 16, 2011
Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory
setting reported to poison centers. Ann Pharmacother. 2011;45(1):17-22. doi:10.1345/aph.1…
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psnet.ahrq.gov/node/45007/psn-pdf
March 30, 2016 - Medication errors involving healthcare students.
March 30, 2016
Hess L, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. March 2016;13:18-23.
https://psnet.ahrq.gov/issue/medication-errors-involving-healthcare-students
Using reports of medication errors submitted to the Pennsylvania Patient Safety Authority that …
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psnet.ahrq.gov/node/43177/psn-pdf
May 14, 2014 - Disclosing medical errors to patients: effects of nonverbal
involvement.
May 14, 2014
Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns.
2014;94(3):310-313. doi:10.1016/j.pec.2013.11.007.
https://psnet.ahrq.gov/issue/disclosing-medical-errors-patients-effects-n…
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psnet.ahrq.gov/node/47611/psn-pdf
January 23, 2019 - Drug and opioid-involved overdose deaths- United States,
2013-2017.
January 23, 2019
Scholl L, Seth P, Kariisa M, et al. Drug and Opioid-Involved Overdose Deaths - United States, 2013-2017.
MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419-1427. doi:10.15585/mmwr.mm675152e1.
https://psnet.ahrq.gov/issue/drug-and-opioi…
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psnet.ahrq.gov/node/35312/psn-pdf
January 02, 2017 - Medication errors involving wrong administration
technique.
January 2, 2017
Santell JP, Cousins DD. Medication Errors Involving Wrong Administration Technique. The Joint
Commission Journal on Quality and Patient Safety. 2016;31(9). doi:10.1016/s1553-7250(05)31068-3.
https://psnet.ahrq.gov/issue/medication-errors-i…
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psnet.ahrq.gov/node/46707/psn-pdf
October 13, 2018 - Medication errors involving nursing students: a
systematic review.
October 13, 2018
Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A
Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481.
https://psnet.ahrq.gov/issue/medication-errors-i…
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psnet.ahrq.gov/issue/barriers-and-facilitators-chemotherapy-patients-engagement-medical-error-prevention
November 02, 2010 - Study
Barriers and facilitators to chemotherapy patients' engagement in medical error prevention.
Citation Text:
Schwappach DLB, Wernli M. Barriers and facilitators to chemotherapy patients' engagement in medical error prevention. Ann Oncol. 2011;22(2):424-30. doi:10.1093/annonc/mdq346…
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psnet.ahrq.gov/node/42503/psn-pdf
September 18, 2013 - The patient is in: patient involvement strategies for
diagnostic error mitigation.
September 18, 2013
McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error
mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-001623.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/37585/psn-pdf
April 29, 2010 - Medication errors involving patient-controlled analgesia.
April 29, 2010
Hicks RW, Sikirica V, Nelson W, et al. Medication errors involving patient-controlled analgesia. Am J Health
Syst Pharm. 2008;65(5):429-40. doi:10.2146/ajhp070194.
https://psnet.ahrq.gov/issue/medication-errors-involving-patient-controlled-a…
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psnet.ahrq.gov/node/39387/psn-pdf
July 23, 2014 - Medication errors involving oral chemotherapy.
July 23, 2014
Weingart SN, Toro J, Spencer J, et al. Medication errors involving oral chemotherapy. Cancer.
2010;116(10):2455-2464. doi:10.1002/cncr.25027.
https://psnet.ahrq.gov/issue/medication-errors-involving-oral-chemotherapy
Widely publicized errors associated w…
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psnet.ahrq.gov/node/40441/psn-pdf
July 02, 2014 - A novel approach to increase residents' involvement in
reporting adverse events.
July 2, 2014
Scott DR, Weimer M, English C, et al. A novel approach to increase residents' involvement in reporting
adverse events. Acad Med. 2011;86(6):742-746. doi:10.1097/ACM.0b013e318217e12a.
https://psnet.ahrq.gov/issue/novel-app…