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  1. The importance of simulation: preventing hand-off mistakes. | PSNet

    psnet.ahrq.gov/issue/importance-simulation-preventing-hand-mistakes
    May 20, 2009 - December 1, 2010 Why nurses make medication errors: a simulation study.

  2. Developing resilience to combat nurse burnout. | PSNet

    psnet.ahrq.gov/issue/developing-resilience-combat-nurse-burnout
    May 01, 2019 - April 27, 2016 Preventing medication errors by empowering patients.

  3. Please, write to me. Writing outpatient clinic letters to patients. Guidance. | PSNet

    psnet.ahrq.gov/issue/please-write-me-writing-outpatient-clinic-letters-patients-guidance
    March 04, 2020 - 2021 WebM&M Cases The Impact of Communication on Medication … Errors March 15, 2021 WebM&M Cases Multiple

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39161/psn-pdf
    December 09, 2009 - Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge. December 9, 2009 Murphy EM, Oxencis CJ, Klauck JA, et al. Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge. A…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42218/psn-pdf
    June 10, 2018 - Your high-alert medication list—relatively useless without associated risk-reduction strategies. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5. https://psnet.ahrq.gov/issue/your-high-alert-medication-list-relatively-useless-without-associated-risk- reduction This newsletter …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37393/psn-pdf
    June 13, 2011 - Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit. June 13, 2011 Grant MJC, Larsen GY. Clinical Information Transfer and Medication Reconciliation in Patients Transferred from the Pediatric Intensive Care Unit. J Patient Saf. 2008;3(4). doi:1…

  7. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. | PSNet

    psnet.ahrq.gov/issue/errors-and-burden-errors-attitudes-perceptions-and-culture-safety-pediatric-cardiac-surgical
    June 16, 2019 - Study Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. Citation Text: Bognár A, Barach P, Johnson J, et al. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac sur…

  8. Patient-physician racial and ethnic concordance and perceived medical errors. | PSNet

    psnet.ahrq.gov/issue/patient-physician-racial-and-ethnic-concordance-and-perceived-medical-errors
    July 27, 2022 - July 24, 2019 ISMP medication error report analysis.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855002/psn-pdf
    November 01, 2023 - Temporarily holding medication orders safely in order to prevent patient harm. November 1, 2023 ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4. https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm Process disconnects can cause administr…

  10. Increasing naloxone prescribing in the emergency department through education and electronic medical record work-aids. | PSNet

    psnet.ahrq.gov/issue/increasing-naloxone-prescribing-emergency-department-through-education-and-electronic-medical
    October 14, 2020 - August 12, 2020 Medication errors in overweight and obese pediatric patients: a systematic … February 9, 2022 Medication error in the care of HIV/AIDS patients: electronic surveillance

  11. Indication-specific opioid prescribing for US patients with Medicaid or private Insurance, 2017 | PSNet

    psnet.ahrq.gov/issue/indication-specific-opioid-prescribing-us-patients-medicaid-or-private-insurance-2017
    August 02, 2017 - August 25, 2021 Medication safety: reducing anesthesia medication errors and adverse … May 6, 2020 ISMP medication error report analysis.

  12. Nurses' influence on consumers' experience of safety in acute mental health units: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/nurses-influence-consumers-experience-safety-acute-mental-health-units-qualitative-study
    January 27, 2021 - October 27, 2021 Use of an audit with feedback implementation strategy to promote medication … error reporting by nurses. … August 5, 2020 Patient safety in home care: a multicenter cross-sectional study about medication … errors and medication management of nurses.

  13. Capturing more emergency department errors via an anonymous web-based reporting system. | PSNet

    psnet.ahrq.gov/issue/capturing-more-emergency-department-errors-anonymous-web-based-reporting-system
    July 22, 2019 - July 16, 2008 Medication error prevention by clinical pharmacists in two children's hospitals

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Vaught was found guilty of criminally negligent homicide and abuse of an impaired adult when a medication … error resulted in a patient death in 2017. … Catastrophic safety events, like medication errors, are almost never caused by isolated errors committed … suicide-risk-changing-jobs-or-leaving-nursing-profession-aftermath-patient-safety-incident https://psnet.ahrq.gov/issue/chronology-medication-errors-nurses-accumulation-stresses-and-ptsd-symptoms

  15. Preventing communication errors in telephone medicine. | PSNet

    psnet.ahrq.gov/issue/preventing-communication-errors-telephone-medicine
    December 01, 2004 - Commentary Preventing communication errors in telephone medicine. Citation Text: Reisman AB, Brown KE. Preventing communication errors in telephone medicine. J Gen Intern Med. 2005;20(10):959-63. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …

  16. Fatal errors in nitrous oxide delivery. | PSNet

    psnet.ahrq.gov/issue/fatal-errors-nitrous-oxide-delivery
    March 02, 2011 - Review Fatal errors in nitrous oxide delivery. Citation Text: Herff H, Paal P, Von Goedecke A, et al. Fatal errors in nitrous oxide delivery. Anaesthesia. 2007;62(12):1202-1206. doi:10.1111/j.1365-2044.2007.05193.x. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…

  17. Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents. | PSNet

    psnet.ahrq.gov/issue/adapting-cognitive-task-analysis-investigate-clinical-decision-making-and-medication-safety
    March 10, 2021 - Study Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents. Citation Text: Russ AL, Militello LG, Glassman PA, et al. Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents. J Patient Sa…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38051/psn-pdf
    May 05, 2018 - Misprogramming PCA concentration leads to dosing errors. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3. https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors This article describes dosing errors associated with improper concentration programming of…

  19. Pilot Testing of Initial Electronic Prescribing Standards (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/eRxReport.pdf
    April 01, 2008 - In hospitals, the average nt is subject to at least one medication error per day.4 This study also … • Assessed standards’ impact on medication errors. 1 5 C. … Preliminary data from this group have demonstrated a potential decrease in medication errors that are … Medication Error: Any error occurring in the medication use process (Bates et al., 1995)11 Includes … Preventing Medication Errors: Quality Chasm Series.

  20. Pilot Testing of Initial Electronic Prescribing Standards (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/eRxReport_041607_1.pdf
    April 01, 2008 - In hospitals, the average nt is subject to at least one medication error per day.4 This study also … • Assessed standards’ impact on medication errors. 1 5 C. … Preliminary data from this group have demonstrated a potential decrease in medication errors that are … Medication Error: Any error occurring in the medication use process (Bates et al., 1995)11 Includes … Preventing Medication Errors: Quality Chasm Series.
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