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  1. Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. | PSNet

    psnet.ahrq.gov/issue/adopt-strategies-manage-look-alike-andor-sound-alike-medication-name-mix-ups
    June 24, 2020 - Newspaper/Magazine Article Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. Citation Text: Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4. Copy …

  2. Health care governance for quality and safety: the new agenda. | PSNet

    psnet.ahrq.gov/issue/health-care-governance-quality-and-safety-new-agenda
    August 09, 2023 - Review Health care governance for quality and safety: the new agenda. Citation Text: Clough J, Nash DB. Health care governance for quality and safety: the new agenda. Am J Med Qual. 2007;22(3):203-13. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNo…

  3. Start the year off right by preventing these top 10 medication errors and hazards from 2020. | PSNet

    psnet.ahrq.gov/issue/start-year-right-preventing-these-top-10-medication-errors-and-hazards-2020
    February 09, 2022 - Newspaper/Magazine Article Start the year off right by preventing these top 10 medication errors and hazards from 2020. Citation Text: Start the year off right by preventing these top 10 medication errors and hazards from 2020. ISMP Medication Safety Alert! Acute care edition. January 27…

  4. High-Alert Medication Learning Guides for Consumers. | PSNet

    psnet.ahrq.gov/issue/high-alert-medication-learning-guides-consumers
    April 30, 2019 - Fact Sheet/FAQs High-Alert Medication Learning Guides for Consumers. Citation Text: High-Alert Medication Learning Guides for Consumers. Horsham, PA: Institute for Safe Medication Practices; 2018.   Copy Citation Save Save to your library Print Download …

  5. The Case for Medication Safety Officers (MSO). | PSNet

    psnet.ahrq.gov/issue/case-medication-safety-officers-mso
    April 30, 2019 - Book/Report The Case for Medication Safety Officers (MSO). Citation Text: The Case for Medication Safety Officers (MSO). Horsham, PA: Institute for Safe Medication Practices; 2018. Copy Citation Save Save to your library Print Download PDF Share …

  6. ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. | PSNet

    psnet.ahrq.gov/issue/ismp-guidelines-sterile-compounding-and-safe-use-sterile-compounding-technology
    November 16, 2022 - Organizational Policy/Guidelines ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. Citation Text: ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. Plymouth Meeting, PA: Institute for Safe Medication Prac…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867845/psn-pdf
    February 26, 2025 - modes (n=32) were not analyzed by any of the 3 facilities in the proactive risk assessments but were listed

  8. 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.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49788/psn-pdf
    March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention March 1, 2017 Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention The Case A 48-year…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49580/psn-pdf
    March 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38612/psn-pdf
    May 06, 2009 - Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home. May 6, 2009 Lee BH, Lehmann CU, Jackson E, et al. Assessing controlled substance prescribing errors in a pediatric teaching …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49571/psn-pdf
    October 01, 2008 - Coming Up Short October 1, 2008 Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/coming-short The Case A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47117/psn-pdf
    November 16, 2018 - Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent. November 16, 2018 Stockwell DC, Landrigan CP, Schuster MA, et al. Using a Pediatric Trigger Tool to Estimate Total Harm Burden Hospital-acquired Conditions Represent. Pediatr Qual Saf. 2018;3(3):e081. doi:10.1097/p…

  14. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation | PSNet

    psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
    March 27, 2024 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation Citation Text: Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation …

  15. Medication discrepancies in integrated electronic health records. | PSNet

    psnet.ahrq.gov/issue/medication-discrepancies-integrated-electronic-health-records
    July 21, 2021 - Study Medication discrepancies in integrated electronic health records. Citation Text: Linsky A, Simon SR. Medication discrepancies in integrated electronic health records. BMJ Qual Saf. 2013;22(2):103-9. doi:10.1136/bmjqs-2012-001301. Copy Citation Format: DOI Google Sch…

  16. Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model. | PSNet

    psnet.ahrq.gov/issue/pharmacist-managed-inpatient-discharge-medication-reconciliation-combined-onsite-and
    July 02, 2019 - Commentary Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model. Citation Text: Keeys C, Kalejaiye B, Skinner M, et al. Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model. Am J H…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49868/psn-pdf
    July 02, 2019 - approach to reviewing this medication error is to evaluate applicable steps in the medication-use process listed

  18. Unintended Consequences of CPOE | PSNet

    psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33567/psn-pdf
    June 15, 2024 - Handoffs June 15, 2024 Handoffs and Signouts. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/handoffs PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Backgroun…

  20. Keeping track of aging patients’ medications. | PSNet

    psnet.ahrq.gov/issue/keeping-track-aging-patients-medications
    December 23, 2020 - Newspaper/Magazine Article Keeping track of aging patients’ medications. Citation Text: Keeping track of aging patients’ medications. Cooney E. Telegram & Gazette. January 27, 2008. Copy Citation Save Save to your library Print Download PDF S…
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