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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42628/psn-pdf
    January 07, 2015 - Engaging patients in medication reconciliation via a patient portal following hospital discharge. January 7, 2015 Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e1):e157-62. doi:10.1136/amiajnl-2…
  2. 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 …
  3. 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. 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…
  5. 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…
  6. 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…
  7. 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 …
  8. 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 …
  9. 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…
  10. 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 …
  11. 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…
  12. 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
  13. 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
  14. 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…
  15. 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…
  16. 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…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49521/psn-pdf
    September 12, 2006 - The Commentary Penicillamine and penicillin are listed as look-alike/sound-alike drugs by the United
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49479/psn-pdf
    April 01, 2005 - Also, as in most hospitals, the nursing medication administration record (MAR) listed the once-daily
  19. psnet.ahrq.gov/web-mm/near-miss-neonate
    August 15, 2018 - would be to instruct trainees to evaluate their own plan of care against the algorithm and guidelines listed
  20. 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…

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