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8781. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
      April 09, 2004 - Errors Reporting Program [MER]; MEDMARxSM, a national database for medication errors). … errors • Aspirations • IV-related • Embolic and related disorders • Laparoscopic complications … error 282 11.5 Delay in treatment 161 6.6 Patient death/injury in restraints 112 4.6 Patient fall … The medication error subcommittee develops medication error reporting categories and the medication … error supplemental form.16 This committee has analyzed 108 medication errors and associated root- cause

8782. Closing the safety loop: evaluation of the National Patient Safety Agency's guidance regarding wristband identification of hospital inpatients. | PSNet
      psnet.ahrq.gov/issue/closing-safety-loop-evaluation-national-patient-safety-agencys-guidance-regarding-wristband
      April 14, 2011 - June 23, 2021 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … December 30, 2014 ISMP medication error report analysis.

8783. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37746/psn-pdf
      May 14, 2008 - Reducing preventable medication safety events by recognizing renal risk. May 14, 2008 Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476.2f. https://psnet.ahrq.gov/issue/red…

8784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41867/psn-pdf
      January 30, 2013 - Medication discrepancies in integrated electronic health records. January 30, 2013 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. https://psnet.ahrq.gov/issue/medication-discrepancies-integrated-electronic-health-…

8785. Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink. | PSNet
      psnet.ahrq.gov/issue/examining-variations-prescribing-safety-uk-general-practice-cross-sectional-study-using
      July 22, 2015 - Study Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink. Citation Text: Stocks J, Kontopantelis E, Akbarov A, et al. Examining variations in prescribing safety in UK general practice: cross sectional stu…

8786. Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics. | PSNet
      psnet.ahrq.gov/issue/alert-burden-pediatric-hospitals-cross-sectional-analysis-six-academic-pediatric-health
      September 29, 2021 - Study Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics. Citation Text: Orenstein EW, Kandaswamy S, Muthu N, et al. Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health …

8787. Dallas Ebola case shows even sound plans can fail spectacularly. | PSNet
      psnet.ahrq.gov/issue/dallas-ebola-case-shows-even-sound-plans-can-fail-spectacularly
      September 30, 2009 - September 21, 2005 Medication error prevention by clinical pharmacists in two children's

8788. PS Grantee | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/index.html?page=0
      December 01, 2024 - Grantee Final Reports: Patient Safety Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety. The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…

8789. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37868/psn-pdf
      June 25, 2008 - Complexity of medication-related verbal orders. June 25, 2008 Wakefield DS, Ward MM, Groath D, et al. Complexity of medication-related verbal orders. Am J Med Qual. 2008;23(1):7-17. doi:10.1177/1062860607310922. https://psnet.ahrq.gov/issue/complexity-medication-related-verbal-orders This descriptive analysis of v…

8790. New Analysis Shows Hospitals Improving Performance on Key Patient Safety Measures Surpassing Pre-pandemic Levels. | PSNet
      psnet.ahrq.gov/issue/new-analysis-shows-hospitals-improving-performance-key-patient-safety-measures-surpassing-pre
      October 23, 2024 - September 21, 2022 ISMP medication error report analysis.

8791. Mentoring staff members as patient safety leaders: the Clarian Safe Passage Program. | PSNet
      psnet.ahrq.gov/issue/mentoring-staff-members-patient-safety-leaders-clarian-safe-passage-program
      January 10, 2011 - 13, 2015 A medication safety education program to reduce the risk of harm caused by medication … errors.

8792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867689/psn-pdf
      March 05, 2025 - Medication administration in aged care facilities: a mixed- methods systematic review. March 5, 2025 Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed?methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318. https://psnet.ahrq.gov/issue/medication-a…

8793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38033/psn-pdf
      September 24, 2010 - Implementing online medication reconciliation at a large academic medical center. September 24, 2010 Bails D, Clayton K, Roy K, et al. Implementing online medication reconciliation at a large academic medical center. Jt Comm J Qual Patient Saf. 2008;34(9):499-508. https://psnet.ahrq.gov/issue/implementing-online-m…

8794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37346/psn-pdf
      March 28, 2012 - Medication administration discrepancies persist despite electronic ordering. March 28, 2012 FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359. https://psnet.ahrq.gov/issue/medic…

8795. On higher ground: ethical reasoning and its relationship with error disclosure. | PSNet
      psnet.ahrq.gov/issue/higher-ground-ethical-reasoning-and-its-relationship-error-disclosure
      July 08, 2020 - Study On higher ground: ethical reasoning and its relationship with error disclosure. Citation Text: Cole AP, Block L, Wu AW. On higher ground: ethical reasoning and its relationship with error disclosure. BMJ Qual Saf. 2013;22(7):580-585. doi:10.1136/bmjqs-2012-001496. Copy Citation…

8796. Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks. | PSNet
      psnet.ahrq.gov/issue/implementation-and-facilitation-post-resuscitation-debriefing-comparative-crossover-study-two
      March 23, 2022 - Study Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks. Citation Text: Kam AJ, Gonsalves CL, Nordlund SV, et al. Implementation and facilitation of post-resuscitation debriefing: a comparative …

8797. Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. | PSNet
      psnet.ahrq.gov/issue/self-reported-medical-medication-and-laboratory-error-eight-countries-risk-factors
      September 19, 2012 - Study Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. Citation Text: Scobie A. Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. Int J Qual Health Care. 2…

8798. Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. | PSNet
      psnet.ahrq.gov/issue/impact-errors-paper-based-and-computerized-diabetes-management-decision-support-hospitalized
      April 03, 2024 - Study Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. Citation Text: Donsa K, Beck P, Höll B, et al. Impact of errors in paper-based and computerize…

8799. Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family. | PSNet
      psnet.ahrq.gov/issue/adverse-event-reviews-healthcare-what-matters-patients-and-their-family-qualitative-study
      March 24, 2021 - Study Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family. Citation Text: McQueen JM, Gibson KR, Manson M, et al. Adverse event reviews in healthcare: what matters to patients and their famil…

8800. Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. | PSNet
      psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned
      January 08, 2020 - Study Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. Citation Text: Salwei ME, Hoonakker PLT, Carayon P, et al. Usability of a human factors-based clinical decision support in the emergency departme…