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psnet.ahrq.gov/node/37032/psn-pdf
May 27, 2011 - Effects of computerized physician order entry and clinical
decision support systems on medication safety: a
systematic review.
May 27, 2011
Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision
support systems on medication safety: a systematic review. Arch Intern Me…
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psnet.ahrq.gov/node/40400/psn-pdf
June 20, 2011 - Determinants of patient-reported medication errors: a
comparison among seven countries.
June 20, 2011
Lu CY, Roughead E. Determinants of patient-reported medication errors: a comparison among seven
countries. Int J Clin Pract. 2011;65(7):733-40. doi:10.1111/j.1742-1241.2011.02671.x.
https://psnet.ahrq.gov/issue/de…
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psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-infusion-pump-safety-ders
March 22, 2023 - Sentinel Event Alerts
Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS.
Citation Text:
Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS. Jt Comm J Qual Patient Saf. 2021;47(6):394-397. doi:10.1016/j.jcjq.2021.03.013.
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psnet.ahrq.gov/issue/eliminating-dangerous-abbreviations-acronyms-and-symbols
June 17, 2014 - Fact Sheet/FAQs
Eliminating Dangerous Abbreviations, Acronyms and Symbols.
Citation Text:
Eliminating Dangerous Abbreviations, Acronyms and Symbols. AHA: American Hosptial Association; American Society of Health-System Pharmacists; AHSP
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psnet.ahrq.gov/issue/when-doctors-admit-their-mistakes
May 01, 2013 - Newspaper/Magazine Article
When doctors admit their mistakes.
Citation Text:
When doctors admit their mistakes. Chen PW.
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psnet.ahrq.gov/node/47750/psn-pdf
January 30, 2019 - Association of adverse effects of medical treatment with
mortality in the United States: a secondary analysis of the
Global Burden of Diseases, Injuries, and Risk Factors
study.
January 30, 2019
Sunshine JE, Meo N, Kassebaum NJ, et al. Association of Adverse Effects of Medical Treatment With
Mortality in the Unit…
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psnet.ahrq.gov/issue/policy-positions-and-guidelines
July 10, 2019 - Database/Directory
Policy Positions and Guidelines.
Citation Text:
Policy Positions and Guidelines. Amercian Society of Health-System Pharmacists; ASHP.
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psnet.ahrq.gov/node/36872/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-12
This monthly selection of medication error reports provides examples of problems related to medication
misadministration, drug shortages, and the appropriate use of the "five rights"…
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psnet.ahrq.gov/node/41456/psn-pdf
September 26, 2016 - Paradoxical effects of a hospital-based, multi-intervention
programme aimed at reducing medication round
interruptions.
September 26, 2016
Tomietto M, Sartor A, Mazzocoli E, et al. Paradoxical effects of a hospital-based, multi-intervention
programme aimed at reducing medication round interruptions. J Nurs Manag. …
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psnet.ahrq.gov/node/41853/psn-pdf
October 08, 2013 - Reported medication events in a paediatric emergency
research network: sharing to improve patient safety.
October 8, 2013
Shaw KN, Lillis KA, Ruddy RM, et al. Reported medication events in a paediatric emergency research
network: sharing to improve patient safety. Emerg Med J. 2013;30(10):815-9. doi:10.1136/emermed…
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psnet.ahrq.gov/node/43623/psn-pdf
September 29, 2017 - Intolerance of error and culture of blame drive medical
excess.
September 29, 2017
Hoffman JR, Kanzaria HK. Intolerance of error and culture of blame drive medical excess. BMJ.
2014;349(oct14 3). doi:10.1136/bmj.g5702.
https://psnet.ahrq.gov/issue/intolerance-error-and-culture-blame-drive-medical-excess
Lack of a…
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psnet.ahrq.gov/node/843092/psn-pdf
January 25, 2023 - Better off at home--how we fail children with complex
medical conditions.
January 25, 2023
Newcomer CA. Better off at home--how we fail children with complex medical conditions. N Engl J Med.
2023;388(3):198-200. doi:10.1056/nejmp2213657.
https://psnet.ahrq.gov/issue/better-home-how-we-fail-children-complex-medica…
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psnet.ahrq.gov/node/44348/psn-pdf
September 04, 2016 - Examining the attitudes of hospital pharmacists to
reporting medication safety incidents using the theory of
planned behaviour.
September 4, 2016
Williams SD, Phipps D, Ashcroft DM. Examining the attitudes of hospital pharmacists to reporting
medication safety incidents using the theory of planned behaviour. Int J…
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psnet.ahrq.gov/node/39823/psn-pdf
April 04, 2011 - Cognitive error as the most frequent contributory factor in
cases of medical injury: a study on verdict's judgment
among closed claims in Japan.
April 4, 2011
Tokuda Y, Kishida N, Konishi R, et al. Cognitive error as the most frequent contributory factor in cases of
medical injury: a study on verdict's judgment am…
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psnet.ahrq.gov/node/44239/psn-pdf
September 29, 2017 - When medical care leads to harm—difficulty finding
words: a teachable moment.
September 29, 2017
Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a
teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/45253/psn-pdf
October 03, 2017 - Patient safety: disclosure of medical errors and risk
mitigation.
October 3, 2017
Moffatt-Bruce SD, Ferdinand FD, Fann J. Patient Safety: Disclosure of Medical Errors and Risk Mitigation.
Ann Thorac Surg. 2016;102(2):358-62. doi:10.1016/j.athoracsur.2016.06.033.
https://psnet.ahrq.gov/issue/patient-safety-disclosu…
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psnet.ahrq.gov/node/47683/psn-pdf
April 10, 2019 - Design of hospital errors and omissions activities that
include patient-specific medication related problems.
April 10, 2019
Cooper JB, Bradley CL. Design of hospital errors and omissions activities that include patient-specific
medication related problems. Curr Pharm Teach Learn. 2019;11(1):66-75. doi:10.1016/j.cp…
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psnet.ahrq.gov/node/73254/psn-pdf
June 02, 2021 - New AHRQ Surveys on Patient Safety Culture Diagnostic
Safety Supplemental Items for Medical Offices.
May 12, 2021
Agency for Healthcare Research and Quality. June 2, 2021.
https://psnet.ahrq.gov/issue/new-ahrq-surveys-patient-safety-culture-diagnostic-safety-supplemental-items-
medical-offices
Measuring and impro…
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psnet.ahrq.gov/node/40784/psn-pdf
September 21, 2011 - Do remote community telepharmacies have higher
medication error rates than traditional community
pharmacies? Evidence from the North Dakota
Telepharmacy Project.
September 21, 2011
Friesner DL, Scott DM, Rathke AM, et al. Do remote community telepharmacies have higher medication
error rates than traditional commu…
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psnet.ahrq.gov/node/60659/psn-pdf
July 08, 2020 - Effects of CPOE-based medication ordering on outcomes:
an overview of systematic reviews.
July 8, 2020
Abraham J, Kitsiou S, Meng A, et al. Effects of CPOE-based medication ordering on outcomes: an
overview of systematic reviews. BMJ Qual Saf. 2020;29(10):854–863. doi:10.1136/bmjqs-2019-010436.
https://psnet.ahrq.…