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www.ahrq.gov/hai/pfp/interimhac2013-ref.html
December 01, 2014 - Preventing medication errors. Washington, DC: National Academies Press; 2006. … http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx
Bates DW, Cullen … Effect of computerized physician order entry and a team intervention on prevention of serious medication … errors. … A report on the relationship of drug names and medication errors in response to the Institute of Medicine
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www.ahrq.gov/hai/pfp/hacrate2013-refs.html
October 01, 2015 - Preventing medication errors. Washington, DC: National Academies Press; 2006. … http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx . … Effect of computerized physician order entry and a team intervention on prevention of serious medication … errors. … A report on the relationship of drug names and medication errors in response to the Institute of Medicine
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psnet.ahrq.gov/node/45537/psn-pdf
July 27, 2018 - ambulatory-care-safety
https://psnet.ahrq.gov/issue/pharmacist-led-information-technology-intervention-medication-errors-pincer-multicentre
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psnet.ahrq.gov/node/73095/psn-pdf
March 31, 2021 - prescriptions often require double-checking and transcription by pharmacist staff to avoid potential
medication … errors.
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psnet.ahrq.gov/node/61093/psn-pdf
November 04, 2020 - impact-nationwide-prospective-drug-utilization-review-program-improve-prescribing-safety
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
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psnet.ahrq.gov/node/847046/psn-pdf
April 05, 2023 - indication-specific-opioid-prescribing-us-patients-medicaid-or-private-insurance-2017
https://psnet.ahrq.gov/issue/indication-based-prescribing-prevents-wrong-patient-medication-errors-computerized-provider
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psnet.ahrq.gov/node/45428/psn-pdf
January 25, 2017 - medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
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psnet.ahrq.gov/node/47105/psn-pdf
August 10, 2018 - prevalence-potentially-inappropriate-medication-use-older-adults-living-nursing-homes
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
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psnet.ahrq.gov/node/50775/psn-pdf
January 01, 2021 - A prior
WebM&M describes a medication error occurring during an intrahospital transfer between the ICU
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psnet.ahrq.gov/issue/awareness-patient-safety-grows-increased-outpatient-surgeries
June 17, 2014 - June 17, 2014
Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance
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psnet.ahrq.gov/issue/managing-hospitalized-patients-ambulatory-pumps-findings-ismp-survey-part-1
November 18, 2015 - Newspaper/Magazine Article
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1.
Citation Text:
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. ISMP Medication Safety Alert! Acute care edition. November 19, 2…
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psnet.ahrq.gov/issue/use-electronic-information-system-identify-adverse-events-resulting-emergency-department
March 13, 2015 - Study
Use of an electronic information system to identify adverse events resulting in an emergency department visit.
Citation Text:
Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify adverse events resulting in an emergency department vi…
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psnet.ahrq.gov/issue/right-medication-right-dose-right-patient-right-time-and-right-route-how-do-we-select-right
March 02, 2016 - Commentary
Right medication, right dose, right patient, right time, and right route: how do we select the right patient-controlled analgesia (PCA) device?
Citation Text:
Ladak SSJ, Chan VWS, Easty T, et al. Right medication, right dose, right patient, right time, and right route: how d…
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psnet.ahrq.gov/issue/promoting-effective-transitions-care-hospital-discharge-review-key-issues-hospitalists
November 16, 2022 - Review
Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.
Citation Text:
Kripalani S, Jackson AT, Schnipper JL, et al. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. …
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psnet.ahrq.gov/node/73987/psn-pdf
October 20, 2021 - Impact of clinical decision support therapeutic
interchanges on hospital discharge medication omissions
and duplications.
October 20, 2021
Maxwell E, Amerine J, Carlton G, et al. Impact of clinical decision support therapeutic interchanges on
hospital discharge medication omissions and duplications. Am J Health Sy…
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psnet.ahrq.gov/node/843325/psn-pdf
February 01, 2023 - Untenable expectations: nurses' work in the context of
medication administration, error, and the organization.
February 1, 2023
Hawkins SF, Morse JM. Untenable expectations: nurses' work in the context of medication administration,
error, and the organization. Glob Qual Nurs Res. 2022;9:233339362211317.
doi:10.117…
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psnet.ahrq.gov/node/43412/psn-pdf
May 28, 2015 - An observational study of how patients are identified
before medication administrations in medical and surgical
wards.
May 28, 2015
Härkänen M, Kervinen M, Ahonen J, et al. An observational study of how patients are identified before
medication administrations in medical and surgical wards. Nurs Health Sci. 2015;1…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication … errors.
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psnet.ahrq.gov/node/33575/psn-pdf
March 15, 2025 - Patient Engagement and Safety
March 15, 2025
Patient Engagement and Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-engagement-and-safety
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 pati…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
January 01, 2004 - Inadequate planning when introducing new technology designed to decrease
medication errors in health