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  1. Oral Dosage Forms that Should Not Be Crushed. | PSNet

    psnet.ahrq.gov/issue/oral-dosage-forms-should-not-be-crushed
    January 26, 2023 - Fact Sheet/FAQs Oral Dosage Forms that Should Not Be Crushed. Citation Text: Oral Dosage Forms that Should Not Be Crushed. Mitchell JF; Institute for Safe Medications Practices; ISMP. Copy Citation Save Save to your library Print Download PDF …

  2. ISMP Survey on High-Alert Medications in Acute Care Settings. | PSNet

    psnet.ahrq.gov/issue/ismp-survey-high-alert-medications-acute-care-settings
    January 26, 2023 - Measurement Tool/Indicator ISMP Survey on High-Alert Medications in Acute Care Settings. Citation Text: ISMP Survey on High-Alert Medications in Acute Care Settings. Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023. Copy Citation Save Save to yo…

  3. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/74277
    January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38608/psn-pdf
    January 02, 2017 - Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting. January 2, 2017 Lesselroth B, Adams S, Felder R, et al. Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting. Jt Comm J Qual Pati…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41898/psn-pdf
    December 05, 2012 - Pharmacy dispensing of electronically discontinued medications. December 5, 2012 Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med. 2012;157(10):700-705. doi:10.7326/0003-4819-157-10-201211200-00006. https://psnet.ahrq.gov/issue/pharmacy-dispensing-electronically-…

  6. Multifactorial Medication Mishap | PSNet

    psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - At this hospital, the CPOE system listed each choice twice, one entry with the generic name and one entry … Even though there were four distinct oxycodone products, eight were listed due to duplication.

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49770/psn-pdf
    September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49727/psn-pdf
    March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36907/psn-pdf
    September 14, 2012 - Serious Reportable Events in Healthcare—2011 Update. September 14, 2012 Washington DC: National Quality Forum; December 2011. https://psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update The National Quality Forum originally defined 27 health care "never events"—patient safety events that pose ser…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41192/psn-pdf
    November 26, 2014 - Effect of patient- and medication-related factors on inpatient medication reconciliation errors. November 26, 2014 Salanitro AH, Osborn CY, Schnipper JL, et al. Effect of patient- and medication-related factors on inpatient medication reconciliation errors. J Gen Intern Med. 2012;27(8):924-932. doi:10.1007/s11606-0…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33779/psn-pdf
    March 01, 2015 - discharge uncovered significant discrepancies between patient-reported medication regimens and those listed

  13. Never Events for Hospital Care in Canada: Safer Care for Patients. | PSNet

    psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients
    August 12, 2020 - Book/Report Never Events for Hospital Care in Canada: Safer Care for Patients. Citation Text: Never Events for Hospital Care in Canada: Safer Care for Patients. Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN: 9781460666180. Copy Cita…

  14. Safety in numbers. | PSNet

    psnet.ahrq.gov/issue/safety-numbers
    November 11, 2015 - Newspaper/Magazine Article Safety in numbers. Citation Text: Safety in numbers. Robeznieks A. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL December 2…

  15. Safety Information for Patients and Families. | PSNet

    psnet.ahrq.gov/issue/safety-information-patients-and-families
    February 05, 2014 - Multi-use Website Safety Information for Patients and Families. Citation Text: Safety Information for Patients and Families. Massachusetts Coalition for the Prevention of Medical Errors; Massachusetts Medical Society Copy Citation Save Save to your library …

  16. Guardians of grafts: reducing medication errors in transplant recipients. | PSNet

    psnet.ahrq.gov/issue/guardians-grafts-reducing-medication-errors-transplant-recipients
    July 17, 2024 - Newspaper/Magazine Article Guardians of grafts: reducing medication errors in transplant recipients. Citation Text: Guardians of grafts: reducing medication errors in transplant recipients. ISMP Medication Safety Alert! Acute care. April 4, 2024;29(7):1-4. Copy Citation …

  17. Medication Reconciliation Pitfalls | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
    May 01, 2006 - Medication Reconciliation Pitfalls Citation Text: Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43486/psn-pdf
    September 01, 2016 - Indication alerts intercept drug name confusion errors during computerized entry of medication orders. September 1, 2016 Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during computerized entry of medication orders. PLoS One. 2014;9(7):e101977. doi:10.1371/journal.pone…

  19. Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains. | PSNet

    psnet.ahrq.gov/issue/cognitive-tests-predict-real-world-errors-relationship-between-drug-name-confusion-rates
    April 12, 2017 - Study Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains. Citation Text: Schroeder SR, Salomon MM, Galanter W, et al. Cognitive tests predict …

  20. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - An autopsy listed the cause of death as multi-organ failure and sepsis caused by necrotic bowel and peritonitis … overly broad nor overly narrow.2 Background (2) Pain attributes and associated symptoms and findings (listed
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