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psnet.ahrq.gov/node/36907/psn-pdf
September 14, 2012 - One
notable addition to the original list is that serious harm associated with failure to properly follow … Since the development and dissemination of this list, many states
have mandated that health care facilities
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psnet.ahrq.gov/issue/using-pediatric-trigger-tool-estimate-total-harm-burden-hospital-acquired-conditions
July 03, 2016 - Hospitals nationwide have invested substantial resources in reducing the HACs on the CMS nonpayment list … proportion of harms that occurred at six children's hospitals were HACs versus harms excluded from the CMS list
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psnet.ahrq.gov/issue/impact-incorporating-pharmacy-claims-data-electronic-medication-reconciliation
September 01, 2016 - medication history about half the time; combining them increased the odds of obtaining a correct medication list … December 9, 2009
An effort to improve electronic health record medication list accuracy
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psnet.ahrq.gov/issue/health-care-consumers-inclination-engage-selected-patient-safety-practices-survey-adults
March 03, 2011 - surgical safety recommend that patients engage in specific safety practices, such as maintaining a list … May 18, 2022
Indication alerts to improve problem list documentation.
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psnet.ahrq.gov/issue/fdas-promised-guidance-pulse-oximeters-unlikely-end-decades-racial-bias
November 06, 2024 - 28, 2024
Health tech hazards: at-home medical devices, AI governance on ECRI's new list … December 20, 2023
Home medical device safety tops ECRI'S list of healthcare technology
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - The patient's medication bottles were given to the ED
triage nurse and were used to generate a list … Among others, the list included "Toprol-
XL 75 mg po daily." … Additionally, the error was propagated by the surgeon, who incorrectly copied the medication list from … medication bottles along
with a verification of those medications against the patient's medication list … for
adequate time to inspect the patient's prescription bottles from home and complete a medication list
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psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
March 27, 2024 - Therefore, a thorough review of the patient’s medication list to identify potential drug-drug interactions … Additionally, the list of drugs that are known to prolong the QTc interval should be readily available … The pharmacy department should regularly review and update this list as part of its patient safety efforts … A list of QTc prolonging medications is available online at: https://crediblemeds.org/healthcare-providers … August 26, 2020
View More
Related Resources
ISMP List of Error-Prone
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psnet.ahrq.gov/issue/patient-safety-healthcare-acquired-conditions-and-serious-reportable-events
March 25, 2025 - announcement provides background on the proposed 2010 effort to revise and expand the National Quality Forum list
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - he was to “resume home diabetic regimen,” but insulin was not included in the discharge medication list … ordered insulin aspart 20-30 units three times daily with meals from the patient’s home medication list … ]) and comparing that list to the prescribing clinician’s admission, transfer, and discharge orders to … Interventions at the Level of the Provider
Obtain an Accurate Medication List
In the first case, … Unfortunately, it is not uncommon to have discrepancies between the patient’s home medication list and
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - Case Objectives
List the goals of having order sets in the electronic health record. … List key principles in the optimal design of order sets. … A commonly used example is in aviation, where completion of a preflight checklist containing a list of … When the majority of interventions on a list are always appropriate, there is a tendency on the part … The preflight checklist model, with its rigid, unvarying list of tasks to be completed is unlikely to
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psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - medications were ordered and required users to click "OK" to ignore the alert, to add the drug
to a problem list … indication-alerts-intercept-drug-name-confusion-errors-during-computerized-entry-medication
https://psnet.ahrq.gov/issue/ismps-list-confused-drug-names
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psnet.ahrq.gov/node/38612/psn-pdf
May 06, 2009 - //psnet.ahrq.gov/issue/adverse-drug-events-pediatric-outpatients
https://psnet.ahrq.gov/issue/ismps-list-high-alert-medications-acute-care-settings … national-surveillance-emergency-department-visits-outpatient-adverse-drug-events-children-and
https://psnet.ahrq.gov/issue/ismp-list-error-prone-abbreviations-symbols-and-dose-designations
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psnet.ahrq.gov/node/47117/psn-pdf
November 16, 2018 - Hospitals nationwide have
invested substantial resources in reducing the HACs on the CMS nonpayment list … proportion of harms that occurred at six children's hospitals were HACs
versus harms excluded from the CMS list
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psnet.ahrq.gov/issue/millions-people-used-tainted-breathing-machines-fda-failed-use-its-power-protect-them
June 28, 2023 - 16, 2024
Health tech hazards: at-home medical devices, AI governance on ECRI's new list … March 8, 2023
Home medical device safety tops ECRI'S list of healthcare technology.
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psnet.ahrq.gov/issue/risk-factors-clinically-relevant-deviations-patients-medication-lists-reported-patients
March 23, 2022 - This study explored clinically relevant deviations in a patient’s medication list by comparing the personal
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psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - One of the first times I remember hearing about the NQF
was when Ken Kizer put out the never events list … Is there a back-story around that, and how has that list
evolved to support the field of patient safety … CC: That list has been a very important one. It's now called the Serious Reportable Events list. … RW: I wonder whether Ken Kizer could have predicted in 2002, when he introduced that list, that a few … Or to Medicare
choosing 6 years later to no longer pay for harms on the list.
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psnet.ahrq.gov/issue/observational-study-drug-formulation-manipulation-pediatric-versus-adult-inpatients
June 08, 2022 - May 31, 2017
Key potentially inappropriate drugs in pediatrics: the KIDs list. … Related Resources
Key potentially inappropriate drugs in pediatrics: the KIDs list
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psnet.ahrq.gov/issue/addressing-racial-and-ethnic-bias-pulse-oximeters-wicked-problem
April 18, 2019 - 16, 2024
Health tech hazards: at-home medical devices, AI governance on ECRI's new list … March 8, 2023
Home medical device safety tops ECRI'S list of healthcare technology.
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psnet.ahrq.gov/issue/problem-never-events
July 12, 2023 - Download Citation
Related Resources From the Same Author(s)
Identifying a list … July 19, 2023
Identifying a list of healthcare 'never events' to effect system change
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - optimally obtain it Understand that transdermal patches have a heightened propensity for error List … They spoke directly with the family and reviewed the official medication reconciliation list, which a … Although the family stated that the patient was on a "memory medicine," the reconciliation list did not … during a care transition, the cholinesterase patch was omitted from the patient's admission medication list … BPMH using a structured patient and/or family interview, followed by verification of this medication list