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4141. Resources by Safety Topic | Agency for Healthcare Research and Quality
      www.ahrq.gov/action-alliance/resources/type-harm.html
      September 01, 2025 - Contents Diagnostic Safety Emergency Preparedness Falls Healthcare-Associated Infections Maternal Safety Medication … Back to Contents Medication Safety AHRQ Medications at Transitions and Clinical Handoffs (MATCH) This … resource features strategies from the field that can help hospitals improve medication reconciliation … resource presents an easy-to-read guide to help nurses or discharge advocates work with patients to track medication

4142. Treatment Challenges After Discharge | PSNet
      psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
      January 03, 2017 - Improving medication education and reconciliation at discharge. … principles and industrial engineering methods to improve accuracy and speed of drug selection with medication … January 3, 2017 ASHP guidelines on preventing medication errors with chemotherapy and … January 26, 2022 Prevalence of potentially harmful multidrug interactions on medication

4143. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
      January 01, 2022 - • Medication reconciliation was completed by the admitting team, confirming that he was opioid-tolerant … Opioid Pharmacokinetics and “Dose Stacking” (4) Providing nurses with a table that notes when the medication … Of note, sedation typically follows medication peak. 22 Medication Onset Peak* Duration* Fentanyl

4144. Team-Based Primary Care: Convergence of Improving Engagement, Safety, and Enhanced Joy in Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teambased-1.pdf
      May 02, 2016 - enhanced processes, including functional and behavioral health screenings, agenda setting, coaching, and medication … reconciliation. … Patient needs between visits, such as followup on test results, triage issues, patient questions, medication … patient together in care gives more people a chance to prevent or catch issues with care, such as medication

4145. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - Communication Improvement (101) Communication between Providers (78) Medication … Reconciliation (11) Read Back Protocols (5) SBAR (2) Structured … Pressure Ulcers (1) Venous Thrombosis and Thromboembolism (3) Medication … Safety (57) Medication Errors/Preventable Adverse Drug Events (37) Administration

4146. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33722/psn-pdf
      December 01, 2011 - The way the model was constructed allowed us to detect side effects of medication so that we didn't … In addition to that, the antiepileptic and benzodiazepine medication categories actually do statistically … consulting with the nurse and care team about all the medications that the patient is on and doing medication … reconciliation, http://www.ncbi.nlm.nih.gov/pubmed/12624858 looking for dose levels and also polypharmacy

4147. Discharge Instructions in the PACU: Who Remembers? | PSNet
      psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
      August 05, 2009 - Moreover, patients' physical and emotional symptoms, the direct effects of medication and treatment, … reduce available working memory at times of information delivery (e.g., pain and physical symptoms; medication … After Discharge November 1, 2010 WebM&M Cases Medication … Reconciliation Pitfalls February 1, 2010 WebM&M Cases

4148. Hard to Swallow | PSNet
      psnet.ahrq.gov/web-mm/hard-swallow
      April 26, 2023 - cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication … March 1, 2011 WebM&M Cases Bad Writing, Wrong Medication … April 1, 2010 WebM&M Cases Medication Reconciliation

4149. The Case of Mistaken Intubation | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-intubation
      July 01, 2016 - WebM&M Cases Syringe Swap During Regional Block: A Case of Medication … August 23, 2017 Medication errors in the care transition of trauma patients December … 18, 2019 Using Healthcare Failure Mode and Effect Analysis to reduce medication errors … Integrated EMR March 1, 2011 WebM&M Cases Medication … Reconciliation Pitfalls February 1, 2010 WebM&M Cases

4150. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest | PSNet
      psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
      February 01, 2023 - 2020 Relationships between medications used in a mental health hospital and types of medication … WebM&M Cases Challenges of Diabetes Management and Medication … Reconciliation August 5, 2022 Annual Perspective … Annual Perspective: Topics in Medication Safety March 31, 2022 Sources … of medication omissions among hospitalized older adults with polypharmacy.

4151. E-cigarette Explosion in a Patient Room | PSNet
      psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
      March 15, 2023 - use of e-cigarettes, all cigarette smokers and e-cigarette users should be offered effective nicotine medication … May 8, 2017 Survey of nurses' experiences applying The Joint Commission's medication … November 3, 2021 Effect of patient- and medication-related factors on inpatient medication … reconciliation errors. … recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication

4152. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
      January 01, 2024 - The algorithm flags possible medication errors if three conditions occur: (1) a medication (Drug A) … Cycloserine was the intended medication. … Evaluate the effectiveness of the EHR strategy to improve medication understanding, reconciliation, … regimen; 2) have fewer discrepancies in their medication lists; 3) take their medication regimen more … use and prompt provider counseling and medication reconciliation.

4153. Enhanced Medication Histories (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/enhancedmedhistories_102611comp.pdf
      October 01, 2011 - Enhanced Medication Histories Enhanced Medication Histories Final ACTION Contract Report … of the general process of Medication Reconciliation. … common medication discrepancy was omission of a regularly used outpatient medication. … Medication History data: 1. … The Medication Hub filters out any medication records that are older than 13 months old.

4154. Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
      January 01, 2023 - drug events.25 – Up to 33% of reported medication errors concern medication administration and 22% … and medications, and medication reconciliation performed by pharmacists.26 29 Prevention of Medication … Reducing medication errors for adults in hospital settings. … Medication Administration - Titration Orders. The Joint Commission. Accessed June 4, 2023. … identify errors related to the medication-use system.

4155. An Etiology for Medication Ordering Errors in CPOE Systems - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs025443-abraham-final-report-2020.pdf
      January 01, 2020 - Limited clinician communication with patients or caregivers about home medication lists and medication … It is a high risk medication” (RN-571). … reconciliation • Set up fatigue protocol to review actions for errors • Include medication indication … Materials and Methods: Erroneous medication orders were captured using a CPOE-based medication voiding … Ordering Errors Medication Voiding and Ordering Errors Impact of Medication Ordering Errors on Safety

4156. HIT for Medication Safety in Critical Access Hospitals - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/p20hs015325-hartzema-final-report-2005.pdf
      January 01, 2005 - Results: HIT in CAHs can impact medication safety at all nodes of the medication use process, from prescribing … technology can play in reducing medication errors at various stages of the medication … pharmacist not present, (5) availability of formularies and safety precautions in drug storage, and (6) reconciliation … Other Considerations n 24hr/7day concurrent Rx review n Controlled access to pharmaceuticals n Reconciliation … the incidence of medication errors arising from every step of the medication use process.

4157. Veterans Affairs Integrated Medication Manager - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017186-nebeker-final-report-2011.pdf
      January 01, 2011 - Veterans Affairs Integrated Medication Manager - Final Report … Refine interfaces and logic of the Integrated Medication Manager. • Aim 2b. … This integrated medication management will be achieved through an application, the Integrated Medication … First, it provides for medication reconciliation that exceeds the standards of Joint Commission rules … Integrated Medication Manager EHR 22 Document title: Veterans Affairs Integrated Medication Manager

4158. Assessing Readiness, Achievement & Impact of Stage 3 Care Coordination Criteria | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/assessing-readiness-achievement-impact-stage-3-care-coordination-criteria
      January 01, 2023 - innovations related to the customization of transition-of-care documents, task tracking, and automated reconciliation

4159. Raise the Bar | PSNet
      psnet.ahrq.gov/web-mm/raise-bar
      May 29, 2024 - Drain in a Patient with Known Latex Allergy August 31, 2022 The effect of medication … reconciliation via a patient portal on medication discrepancies: a randomized noninferiority study.

4160. Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell-R_106.pdf
      April 14, 2008 - risk assessment of drugs, medication reconciliation, and safer outpatient medication usage. … Proactive medication safety studies that incorporate medication and comorbidity profiles, a common occurrence … Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP) USP-ISMP Medication Errors … Preventing medication errors: Quality chasm series. … Medication error reporting systems. In: Medication errors. 2nd ed.