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Showing results for "medication errors".
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  1. Losing Laura. | PSNet

    psnet.ahrq.gov/issue/losing-laura
    June 06, 2018 - Related Resources From the Same Author(s) Report faults Children's Hospital for medication … errors.

  2. Patients put at risk by NHS computer fault. | PSNet

    psnet.ahrq.gov/issue/patients-put-risk-nhs-computer-fault
    November 04, 2012 - Providers Health Care Executives and Administrators Information Professionals Patients Medication … Errors/Preventable Adverse Drug Events View More

  3. Managing the risks of direct oral anticoagulants. | PSNet

    psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
    December 23, 2016 - September 23, 2020 Direct oral anticoagulants: a review of common medication errors.

  4. Forgive and forget: recognition of error and use of apology as preemptive steps to ADR or litigation in medical malpractice cases. | PSNet

    psnet.ahrq.gov/issue/forgive-and-forget-recognition-error-and-use-apology-preemptive-steps-adr-or-litigation
    July 24, 2018 - December 16, 2020 Analysis of iatrogenic and in-hospital medication errors reported to

  5. Stop the silent misdiagnosis: patients' preferences matter. | PSNet

    psnet.ahrq.gov/issue/stop-silent-misdiagnosis-patients-preferences-matter
    February 02, 2020 - August 5, 2020 Medication errors associated with transition from insulin pens to insulin

  6. AI can't replace doctors. But it can make them better. | PSNet

    psnet.ahrq.gov/issue/ai-cant-replace-doctors-it-can-make-them-better
    September 03, 2014 - June 14, 2019 Evaluation of an electronic dosing calculator to reduce pediatric medication … errors.

  7. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    June 01, 2025 - Medication-Assisted Treatment (Not reviewed) (Not reviewed) Summary of Evidence (Not reviewed) ADEs: Infusion Pumps/Medication … Error Patient Safety Practices MHS I (2001) MHS II (2013) MHS III (2020) MHS IV (2023-24) Smart Pumps

  8. Clinical Practice Improvement and Redesign: How Change in Workflow Can Be Supported by Clinical Decision Support (pdf file)

    digital.ahrq.gov/sites/default/files/docs/biblio/09-0054-EF-Updated_0.pdf
    June 01, 2009 - Clinical decision Preventing Medication Errors. … Preventing support in electronic prescribing: Medication Errors, Institute of Medicine. … facilitating medication errors. JAMA 60. … JAMA Mar medication errors: descriptive analysis of events 2005;293(10):1223-38. … J Patient approach to predicting the effectiveness of Saf 2006;2(1):25-32. medication error interventions

  9. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet

    psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - They concluded that each interruption results in a 12.7% increased risk of a medication error and that … individually and collectively, to ensure that they actually do reduce the frequency and severity of medication … errors without negative unanticipated consequences.( 5 ) Certain clinical environments such as the … errors ( 14 ) or interruptions.( 2 ) The adoption of this strategy appears somewhat limited perhaps … Keep away: Kaiser South San Francisco RNs don yellow sashes to reduce interruptions and medication errors

  10. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
    November 01, 2011 - Spotlight Case July 2008 Spotlight Case Near Miss with Bedside Medications * * Source and Credits This presentation is based on the November 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…

  11. Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness. | PSNet

    psnet.ahrq.gov/issue/intensive-care-unit-nurses-information-needs-and-recommendations-integrated-displays-improve
    March 01, 2011 - Study Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness. Citation Text: Koch SH, Weir C, Haar M, et al. Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurs…

  12. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Review of nationally reported opioid-related sentinel events found that 75% were attributable to medication … error and improper monitoring 12 Opioid-Induced Respiratory Depression (3) 13 • Majority of PCA … Medication errors involving patient-controlled analgesia.

  13. The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study. | PSNet

    psnet.ahrq.gov/issue/surgeon-second-victim-results-boston-intraoperative-adverse-events-surgeons-attitude-bisa
    January 23, 2017 - July 25, 2018 Making an infusion error: the second victims of infusion therapy-related medication … errors.

  14. The effect of emergency department boarding on order completion. | PSNet

    psnet.ahrq.gov/issue/effect-emergency-department-boarding-order-completion
    January 29, 2018 - (s) A randomized controlled trial on the effect of a double check on the detection of medication … errors.

  15. Defining, estimating, and communicating overdiagnosis in cancer screening. | PSNet

    psnet.ahrq.gov/issue/defining-estimating-and-communicating-overdiagnosis-cancer-screening
    October 13, 2018 - , 2022 View More Related Resources Clinicians' perceptions of medication … errors with opioids in cancer and palliative care services: a priority setting report.

  16. Impact of alarm fatigue on the work of nurses in an intensive care environment--a systematic review. | PSNet

    psnet.ahrq.gov/issue/impact-alarm-fatigue-work-nurses-intensive-care-environment-systematic-review
    August 31, 2022 - November 7, 2018 Moral distress, compassion fatigue, and perceptions about medication … errors in certified critical care nurses.

  17. Scoping review of the second victim syndrome among surgeons: understanding the impact, responses, and support systems. | PSNet

    psnet.ahrq.gov/issue/scoping-review-second-victim-syndrome-among-surgeons-understanding-impact-responses-and
    March 24, 2019 - March 5, 2025 A review of medication errors and the second victim in pediatric pharmacy

  18. Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality. | PSNet

    psnet.ahrq.gov/issue/ambulance-diversion-associated-reduced-access-cardiac-technology-and-increased-one-year
    October 27, 2016 - May 9, 2012 Factors influencing medication errors in the prehospital paramedic environment

  19. Uncertain diagnoses in a children's hospital: patient characteristics and outcomes. | PSNet

    psnet.ahrq.gov/issue/uncertain-diagnoses-childrens-hospital-patient-characteristics-and-outcomes
    March 17, 2021 - October 28, 2020 Impact of pharmacist interventions on medication errors in hospitalized

  20. Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature. | PSNet

    psnet.ahrq.gov/issue/overlooked-guide-wire-multicomplicated-swiss-cheese-model-example-analysis-case-and-review
    September 15, 2021 - Related Resources From the Same Author(s) Effect of a mobile app on prehospital medication … errors during simulated pediatric resuscitation: a randomized clinical trial.
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