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psnet.ahrq.gov/node/39428/psn-pdf
April 07, 2010 - failure, resuscitation equipment not available, physical
environment, insufficient monitoring, and medication … error.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
June 16, 2008 - error reporting,10 primary care error taxonomy8), such application-specific and oft
organization-specific … Errors has a very detaile
classification of product labeling issues as a cause of error that is not … errors
• Lack of intervention
on the patient’s behalf
• Lack of prevention
• Missed or mistaken … National Coordinating Council on Medication Error
Reporting and Prevention. … Taxonomy of medication
errors. Available at: www.nccmerp.org/pdf/taxo2001-
07-31.pdf.
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psnet.ahrq.gov/node/43662/psn-pdf
November 05, 2014 - A crack in our best armor: "wrong patient" injections from
insulin pens alarmingly frequent even with barcode
scanning.
November 5, 2014
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
https://psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-
fr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
April 22, 2004 - Medication
errors observed in 36 health care facilities. … Medication
errors and pediatric inpatients. JAMA 2001
Apr;285(16):2114–20.
27.
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psnet.ahrq.gov/issue/actively-caring-safety-overcoming-bystander-apathy
December 03, 2014 - Newspaper/Magazine Article
Actively caring for safety: overcoming bystander apathy.
Citation Text:
Actively caring for safety: overcoming bystander apathy. ISMP Medication Safety Alert! Acute Care Edition. November 20, 2008:13:1-3.
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psnet.ahrq.gov/issue/fatal-outcome-after-inadvertent-injection-topical-epinephrine
May 07, 2018 - Newspaper/Magazine Article
Fatal outcome after inadvertent injection of topical epinephrine.
Citation Text:
Fatal outcome after inadvertent injection of topical epinephrine. ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.
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…
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digital.ahrq.gov/sites/default/files/docs/resource/Dataform_3_Medication_Error_and_Near_Miss_Classification_Form.pdf
June 16, 2021 - DATAFORM 3 Medication Error and Near Miss Classification Form
WBD
DATAFORM 3
Medication Error … 2
Center of Excellence for Patient Safety Research and Practice 5/27/05
Dataform 3: Medication … Error and Near Miss Classification Form Version 0.3
Codes for … Error and Near Miss Classification Form Version 0.3
WBD
DATAFORM … 3
Medication Error and Near Miss
Classification Form
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psnet.ahrq.gov/issue/opioid-crisis-origins-trends-policies-and-roles-pharmacists
December 14, 2022 - March 17, 2021
ISMP medication error report analysis. … June 16, 2019
ISMP medication error report analysis.
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digital.ahrq.gov/ahrq-funded-projects/using-social-knowledge-networking-skn-technology-enable-meaningful-use-ehr
January 01, 2023 - Medication Reconciliation
Medication Safety
Sociotechnical Aspects
Transitions in Care
Medication … errors are a major contributor to adverse patient outcomes and increased healthcare costs. … This process significantly reduces the risk of medication errors during care transitions, improves patient
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digital.ahrq.gov/track-8-patient-and-family-centered-health-it-and-safety
January 01, 2023 - Participants will learn how to recognize some of the causal factors linked to medication errors and develop
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psnet.ahrq.gov/node/842415/psn-pdf
January 11, 2023 - Accuracy of spinal anesthesia drug concentrations in
mixtures prepared by anesthetists.
January 11, 2023
Heesen M, Steuer C, Wiedemeier P, et al. Accuracy of spinal anesthesia drug concentrations in mixtures
prepared by anesthetists. J Patient Saf. 2022;18(8):e1226-e1230. doi:10.1097/pts.0000000000001061.
https://…
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psnet.ahrq.gov/node/60600/psn-pdf
June 17, 2020 - Reasons for drug administration problems and perceived
needs for assistance of patients, family caregivers, and
nurses: a qualitative study.
June 17, 2020
Lampert A, Haefeli WE, Seidling HM. Reasons for drug administration problems and perceived needs for
assistance of patients, family caregivers, and nurses: a qu…
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psnet.ahrq.gov/issue/patient-safety-dialysis-facility
May 27, 2015 - Commentary
Patient safety in the dialysis facility.
Citation Text:
Kliger AS. Patient safety in the dialysis facility. Blood Purif. 2006;24(1):19-21.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - recent implementation of bar code medication administration at Veterans hospitals was designed to reduce medication … errors. … July 13, 2016
Profiles in patient safety: medication errors in the emergency department
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psnet.ahrq.gov/issue/thinking-outside-pillbox-system-wide-approach-improving-patient-medication-adherence-chronic
January 20, 2016 - November 2, 2011
Out-of-hospital medication errors: a 6-year analysis of the national
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psnet.ahrq.gov/issue/quality-related-event-learning-community-pharmacies-manual-versus-computerized-reporting
November 09, 2016 - December 18, 2024
Identifying, understanding and overcoming barriers to medication error … September 4, 2019
ISMP medication error report analysis.
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psnet.ahrq.gov/issue/back-basics-checklists-aviation-and-healthcare
May 15, 2024 - Commentary
Back to basics: checklists in aviation and healthcare.
Citation Text:
Clay-Williams R, Colligan L. Back to basics: checklists in aviation and healthcare. BMJ Qual Saf. 2015;24(7):428-31. doi:10.1136/bmjqs-2015-003957.
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psnet.ahrq.gov/issue/randomized-trial-improve-prescribing-safety-during-pregnancy
October 06, 2011 - Study
Randomized trial to improve prescribing safety during pregnancy.
Citation Text:
Raebel MA, Carroll NM, Kelleher JA, et al. Randomized trial to improve prescribing safety during pregnancy. J Am Med Inform Assoc. 2007;14(4):440-450.
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psnet.ahrq.gov/issue/hospitalist-handoffs-systematic-review-and-task-force-recommendations
September 09, 2013 - Review
Hospitalist handoffs: a systematic review and task force recommendations.
Citation Text:
Arora VM, Manjarrez E, Dressler DD, et al. Hospitalist handoffs: A systematic review and task force recommendations. J Hosp Med. 2009;4(7). doi:10.1002/jhm.573.
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…
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psnet.ahrq.gov/issue/clinical-information-transfer-and-medication-reconciliation-patients-transferred-pediatric
September 28, 2010 - Study
Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit.
Citation Text:
Grant MJC, Larsen GY. Clinical Information Transfer and Medication Reconciliation in Patients Transferred from the Pediatric Intensive Care U…