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psnet.ahrq.gov/node/46139/psn-pdf
September 23, 2017 - Impact of interruptions, distractions, and cognitive load
on procedure failures and medication administration
errors.
September 23, 2017
Thomas L, Donohue-Porter P, Fishbein JS. Impact of Interruptions, Distractions, and Cognitive Load on
Procedure Failures and Medication Administration Errors. J Nurs Care Qual. 2…
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psnet.ahrq.gov/node/39841/psn-pdf
December 18, 2014 - Emergency department visits for medical
device–associated adverse events among children.
December 18, 2014
Wang C, Hefflin B, Cope JU, et al. Emergency department visits for medical device-associated adverse
events among children. Pediatrics. 2010;126(2):247-59. doi:10.1542/peds.2010-0528.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/43918/psn-pdf
September 27, 2017 - Medication-administration errors in an urban mental
health hospital: a direct observation study.
September 27, 2017
Cottney A, Innes J. Medication-administration errors in an urban mental health hospital: a direct
observation study. Int J Ment Health Nurs. 2015;24(1):65-74. doi:10.1111/inm.12096.
https://psnet.ahr…
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psnet.ahrq.gov/node/44187/psn-pdf
November 10, 2015 - A safe practice standard for barcode technology.
November 10, 2015
Leung AA, Denham CR, Gandhi TK, et al. A safe practice standard for barcode technology. J Patient Saf.
2015;11(2):89-99. doi:10.1097/PTS.0000000000000049.
https://psnet.ahrq.gov/issue/safe-practice-standard-barcode-technology
Barcode technology has…
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psnet.ahrq.gov/node/72470/psn-pdf
January 01, 2021 - Safe use of the EHR by medical scribes: a qualitative
study.
November 18, 2020
Ash JS, Corby S, Mohan V, et al. Safe use of the EHR by medical scribes: a qualitative study. J Amer Med
Inform Assoc. 2021;28(2):294-302. doi:10.1093/jamia/ocaa199.
https://psnet.ahrq.gov/issue/safe-use-ehr-medical-scribes-qualitative-…
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psnet.ahrq.gov/node/50552/psn-pdf
October 16, 2019 - Moral distress in intensive care unit personnel is not
consistently associated with adverse medication events
and other adverse events
October 16, 2019
Dodek P, Norena M, Ayas N, et al. Moral distress in intensive care unit personnel is not consistently
associated with adverse medication events and other adverse e…
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psnet.ahrq.gov/node/46632/psn-pdf
May 11, 2019 - Higher accuracy of complex medication reconciliation
through improved design of electronic tools.
May 11, 2019
Horsky J, Drucker EA, Ramelson HZ. Higher accuracy of complex medication reconciliation through
improved design of electronic tools. J Am Med Inform Assoc. 2018;25(5):465-475.
doi:10.1093/jamia/ocx127.
h…
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psnet.ahrq.gov/node/44059/psn-pdf
April 22, 2015 - ASHP guidelines on preventing medication errors with
chemotherapy and biotherapy.
April 22, 2015
Goldspiel B, Hoffman JM, Griffith NL, et al. ASHP guidelines on preventing medication errors with
chemotherapy and biotherapy. Am J Health Syst Pharm. 2015;72(8):e6-e35. doi:10.2146/sp150001.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/42497/psn-pdf
February 27, 2014 - (How) do we learn from errors? A prospective study of the
link between the ward's learning practices and medication
administration errors.
February 27, 2014
Drach-Zahavy A, Somech A, Admi H, et al. (How) do we learn from errors? A prospective study of the link
between the ward's learning practices and medication a…
-
psnet.ahrq.gov/node/47887/psn-pdf
August 07, 2019 - Nurses' safety motivation: examining predictors of
nurses' willingness to report medication errors.
August 7, 2019
Farag A, Lose D, Gedney-Lose A. Nurses' Safety Motivation: Examining Predictors of Nurses' Willingness
to Report Medication Errors. West J Nurs Res. 2019;41(7):954-972. doi:10.1177/0193945918815462.
h…
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psnet.ahrq.gov/node/46808/psn-pdf
February 14, 2018 - Anesthesia medication handling needs a new vision.
February 14, 2018
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg.
2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
Anesthesiology has been a le…
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psnet.ahrq.gov/node/44555/psn-pdf
October 07, 2015 - Learning without borders: a review of the implementation
of medical error reporting in Médecins Sans Frontières.
October 7, 2015
Shanks L, Bil K, Fernhout J. Learning without Borders: A Review of the Implementation of Medical Error
Reporting in Médecins Sans Frontières. PLoS One. 2015;10(9):e0137158.
doi:10.1371/j…
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psnet.ahrq.gov/node/72584/psn-pdf
December 16, 2020 - Hidden medication loss when using a primary
administration set for small-volume intermittent infusions.
December 16, 2020
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-
intermittent
…
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psnet.ahrq.gov/node/46563/psn-pdf
February 07, 2018 - Near-miss medication errors provide a wake-up call.
February 7, 2018
Claffey C. Near-miss medication errors provide a wake-up call. Nursing (Brux). 2018;48(1):53-55.
doi:10.1097/01.NURSE.0000527615.45031.9e.
https://psnet.ahrq.gov/issue/near-miss-medication-errors-provide-wake-call
Case studies of adverse events a…
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psnet.ahrq.gov/node/36494/psn-pdf
August 29, 2016 - Medication prescribing errors involving the route of
administration.
August 29, 2016
Lesar TS. Medication Prescribing Errors Involving the Route of Administration. Hosp Pharm.
2010;41(11):1053-1066. doi:10.1310/hpj4111-1053.
https://psnet.ahrq.gov/issue/medication-prescribing-errors-involving-route-administration
…
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psnet.ahrq.gov/node/44320/psn-pdf
October 28, 2015 - Interventions for reducing medication errors in children in
hospital.
October 28, 2015
Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in
hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3.
https://psnet.ahrq.gov/issue/int…
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psnet.ahrq.gov/node/43937/psn-pdf
May 05, 2018 - Getting closer to the bull's eye: 2014–2015 Targeted
Medication Safety Best Practices.
May 5, 2018
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
https://psnet.ahrq.gov/issue/getting-closer-bulls-eye-2014-2015-targeted-medication-safety-best-practices
Benchmarks tracking a wide spectru…
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psnet.ahrq.gov/node/844554/psn-pdf
February 15, 2023 - Medication mix-up: what happened at Vanderbilt and how
it impacts health care providers.
February 15, 2023
Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71
https://psnet.ahrq.gov/issue/medication-mix-what-happened-vanderbilt-and-how-it-impacts-health-care-
providers
High-profile medication errors like tha…
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psnet.ahrq.gov/node/35835/psn-pdf
June 13, 2011 - JCAHO tightens leash on medication reconciliation.
June 13, 2011
Perry LE. Drug Topics. March 20, 2006.
https://psnet.ahrq.gov/issue/jcaho-tightens-leash-medication-reconciliation
This article reports on the Joint Commission's focus on medication reconciliation and illustrates how health
care organizations are app…
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psnet.ahrq.gov/issue/intravenous-chemotherapy-compounding-errors-follow-pan-canadian-observational-study
March 18, 2011 - Study
Intravenous chemotherapy compounding errors in a follow-up pan-Canadian observational study.
Citation Text:
Gilbert RE, Kozak MC, Dobish RB, et al. Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study. J Oncol Pract. 2018;14(5):e295-e303. doi:…