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psnet.ahrq.gov/node/38645/psn-pdf
February 15, 2011 - A comprehensive pharmacist intervention to reduce
morbidity in patients 80 years or older: a randomized
controlled trial.
February 15, 2011
Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in
patients 80 years or older: a randomized controlled trial. Arch Inter…
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psnet.ahrq.gov/node/41875/psn-pdf
September 19, 2016 - Medical error: the second victim.
September 19, 2016
McCay L, Wu AW. Medical error: the second victim. Br J Hosp Med (Lond). 2012;73(10):C146-148.
https://psnet.ahrq.gov/issue/medical-error-second-victim-0
Exploring how medical errors affect second victims, this commentary recommends strategies to help them
cope w…
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psnet.ahrq.gov/node/36989/psn-pdf
June 18, 2013 - Medication Management: Detailed Use Case.
June 18, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology, US Department of
Health and Human Services; 2007.
https://psnet.ahrq.gov/issue/medication-management-detailed-use-case
This report provides two example scenarios—inpatient m…
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psnet.ahrq.gov/node/39411/psn-pdf
May 31, 2016 - Medication communication: a concept analysis.
May 31, 2016
Manias E. Medication communication: a concept analysis. J Adv Nurs. 2010;66(4):933-43.
doi:10.1111/j.1365-2648.2009.05225.x.
https://psnet.ahrq.gov/issue/medication-communication-concept-analysis
This article reviews aspects of medication communication and…
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psnet.ahrq.gov/node/34014/psn-pdf
January 25, 2008 - Medication errors in pediatrics—the octopus evading
defeat.
January 25, 2008
Sullivan JE, Buchino JJ. Medication errors in pediatrics--the octopus evading defeat. J Surg Oncol.
2004;88(3):182-8.
https://psnet.ahrq.gov/issue/medication-errors-pediatrics-octopus-evading-defeat
This review examines pediatric medicat…
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psnet.ahrq.gov/node/42077/psn-pdf
April 05, 2016 - ASHP statement on the pharmacist's role in medication
reconciliation.
April 5, 2016
ASHP Statement on the Pharmacist’s Role in Medication Reconciliation. Am J Health Syst Pharm.
2013;70(5):453-456. doi:10.2146/sp120009.
https://psnet.ahrq.gov/issue/ashp-statement-pharmacists-role-medication-reconciliation
This st…
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psnet.ahrq.gov/node/38221/psn-pdf
June 13, 2011 - Medication reconciliation in a community, nonteaching
hospital.
June 13, 2011
Wortman SB. Medication reconciliation in a community, nonteaching hospital. Am J Health Syst Pharm.
2008;65(21):2047-54. doi:10.2146/ajhp080091.
https://psnet.ahrq.gov/issue/medication-reconciliation-community-nonteaching-hospital
This …
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psnet.ahrq.gov/node/34608/psn-pdf
March 28, 2005 - Center for Medical Simulation.
March 28, 2005
https://psnet.ahrq.gov/issue/center-medical-simulation
The Center for Medical Simulation (CMS) is a not-for-profit corporation founded by the anesthesia
departments of the Harvard Medical School affiliated hospitals. CMS dedicates its efforts to provide
medical educati…
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psnet.ahrq.gov/node/36514/psn-pdf
May 11, 2014 - Medication reconciliation physician order form.
May 11, 2014
Lacy JL, Wilkinson ST. Medication Reconciliation Physician Order Form. Hosp Pharm. 2010;41(11):1117-
1119. doi:10.1310/hpj4111-1117.
https://psnet.ahrq.gov/issue/medication-reconciliation-physician-order-form
The authors discuss background on one hospita…
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psnet.ahrq.gov/node/42041/psn-pdf
July 01, 2013 - Clinical errors and medical negligence.
July 1, 2013
Oyebode F. Clinical errors and medical negligence. Med Princ Pract. 2013;22(4):323-33.
doi:10.1159/000346296.
https://psnet.ahrq.gov/issue/clinical-errors-and-medical-negligence
This review discusses patterns of medical errors that result in malpractice claims, …
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psnet.ahrq.gov/node/38629/psn-pdf
May 20, 2009 - Medication errors in an intensive care unit.
May 20, 2009
Bohomol E, Ramos LH, D'Innocenzo M. Medication errors in an intensive care unit. J Adv Nurs.
2009;65(6):1259-67. doi:10.1111/j.1365-2648.2009.04979.x.
https://psnet.ahrq.gov/issue/medication-errors-intensive-care-unit
Pharmacy problems, including lack of me…
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psnet.ahrq.gov/node/41315/psn-pdf
October 10, 2012 - 2012 ISMP International Medication Safety Self
Assessment for Oncology.
October 10, 2012
Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada.
https://psnet.ahrq.gov/issue/2012-ismp-international-medication-safety-self-assessment-oncology
This tool evaluates the safety of canc…
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psnet.ahrq.gov/node/41350/psn-pdf
May 02, 2012 - Medication reconciliation in the hospital: what, why,
where, when, who and how?
May 2, 2012
Fernandes O; Shojania KG.
https://psnet.ahrq.gov/issue/medication-reconciliation-hospital-what-why-where-when-who-and-how
This commentary examines the practical considerations required to implement a high quality medication…
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psnet.ahrq.gov/issue/follow-markedly-elevated-serum-potassium-results-ambulatory-setting-implications-patient
September 29, 2021 - Study
Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety.
Citation Text:
Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety. Moore CR; Lin JJ; O'Connor N; Hal…
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psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections
June 10, 2018 - Newspaper/Magazine Article
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.
Citation Text:
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. ISMP Medication Safety Alert! Acute care edition. July 26, 2007.
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psnet.ahrq.gov/issue/complexity-bullying-and-stress-analyzing-and-mitigating-challenging-work-environment-nurses
June 09, 2011 - Commentary
Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses.
Citation Text:
Hughes RG, Clancy CM. Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses. J Nurs Care Qual. 2009;24(3):180-18…
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psnet.ahrq.gov/issue/survey-lasa-drug-name-pairs-who-knows-whats-your-list-and-best-ways-prevent-mix-ups
June 10, 2018 - Newspaper/Magazine Article
Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?
Citation Text:
Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups? ISMP Medication Safety Alert! Acute Care Editi…
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psnet.ahrq.gov/issue/sorry-works-20-disclosure-apology-and-relationships-prevent-medical-malpractice-claims
November 30, 2007 - Book/Report
Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims.
Citation Text:
Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims. Wojcieszak D, Saxton JW, Finkelstein MM. Bloomington, IN: AuthorHouse; …
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psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
June 10, 2018 - Newspaper/Magazine Article
ISMP updates its list of drug name pairs with Tall man letters.
Citation Text:
ISMP updates its list of drug name pairs with Tall man letters. ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.
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psnet.ahrq.gov/issue/using-pharmacogenetics-improve-drug-safety-and-efficacy
November 18, 2016 - Commentary
Using pharmacogenetics to improve drug safety and efficacy.
Citation Text:
Haga SB, Burke W. Using pharmacogenetics to improve drug safety and efficacy. JAMA. 2004;291(23):2869-71.
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