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psnet.ahrq.gov/node/854833/psn-pdf
October 25, 2023 - Deficiencies in Facility Leaders' Response to Critical
Surgical Events at the Michael E. DeBakey VA Medical
Center in Houston, Texas.
October 25, 2023
Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.
https://psnet.ahrq.gov/issue/deficiencies-facility-leaders-respons…
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psnet.ahrq.gov/node/60898/psn-pdf
September 09, 2020 - Sequential implementation of the EQUIPPED geriatric
medication safety program as a learning health system.
September 9, 2020
Vandenberg AE, Kegler M, Hastings SN, et al. Sequential implementation of the EQUIPPED geriatric
medication safety program as a learning health system. Int J Qual Health Care. 2020;32(7):470-…
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psnet.ahrq.gov/node/74055/psn-pdf
January 01, 2022 - Registered nurses' and medical doctors' experiences of
patient safety in health information exchange during
interorganizational care transitions: a qualitative review.
November 10, 2021
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. Registered nurses' and medical doctors' experiences of
patient safety in health …
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psnet.ahrq.gov/node/43277/psn-pdf
June 18, 2014 - The Food and Drug Administration's initiative for safe
design and effective use of home medical equipment.
June 18, 2014
Weick-Brady M, Singh S. The Food and Drug Administration's initiative for safe design and effective use of
home medical equipment. Home Healthc Nurse. 2014;32(6):343-8. doi:10.1097/NHH.0000000000…
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psnet.ahrq.gov/node/862150/psn-pdf
February 07, 2024 - Effectiveness of ChatGPT in clinical pharmacy and the
role of artificial intelligence in medication therapy
management.
February 7, 2024
Roosan D, Padua P, Khan R, et al. Effectiveness of ChatGPT in clinical pharmacy and the role of artificial
intelligence in medication therapy management. J Am Pharm Assoc (2003).…
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psnet.ahrq.gov/node/46728/psn-pdf
March 27, 2018 - Near-miss event analysis enhances the barcode
medication administration process.
March 27, 2018
Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M.
https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-
process
Near misses provide unique opportunities to ide…
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psnet.ahrq.gov/node/36550/psn-pdf
January 12, 2011 - Effects of technological interventions on the safety of a
medication-use system.
January 12, 2011
Skibinski K, White BA, Lin LI-K, et al. Effects of technological interventions on the safety of a medication-
use system. Am J Health Syst Pharm. 2007;64(1):90-6.
https://psnet.ahrq.gov/issue/effects-technological-int…
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psnet.ahrq.gov/node/38439/psn-pdf
December 23, 2012 - Legality of technicians' involvement in medication
reconciliation not clear.
December 23, 2012
Thompson CA. Legality of technicians' involvement in medication reconciliation not clear. American journal
of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.
2009;66…
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psnet.ahrq.gov/node/35538/psn-pdf
March 29, 2010 - Identifying medical errors: developing consensus on
classifications and consequences.
March 29, 2010
Hobgood C; Eaton J; Weiner BJ.
https://psnet.ahrq.gov/issue/identifying-medical-errors-developing-consensus-classifications-and-
consequences
The investigators surveyed a panel of experts to determine if they coul…
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psnet.ahrq.gov/node/41831/psn-pdf
December 31, 2012 - The economics of health care quality and medical errors.
December 31, 2012
Andel C, Davidow SL, Hollander M, et al. The economics of health care quality and medical errors. J Health
Care Finance. 2012;39(1):39-50.
https://psnet.ahrq.gov/issue/economics-health-care-quality-and-medical-errors
Discussing the financia…
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psnet.ahrq.gov/node/41943/psn-pdf
August 15, 2013 - Medication reconciliation: a qualitative analysis of
clinicians' perceptions.
August 15, 2013
Vogelsmeier A, Pepper GA, Oderda L, et al. Medication reconciliation: A qualitative analysis of clinicians'
perceptions. Res Social Adm Pharm. 2013;9(4):419-30. doi:10.1016/j.sapharm.2012.08.002.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/35336/psn-pdf
June 17, 2014 - Medication safety issue brief. Bar code implementation
strategies.
June 17, 2014
Association AH, Pharmacists AS of H-S, Networks H and H. Medication Safety Issue Brief. Bar Code
implementation strategies. Hospitals & health networks. 2005;79(7):65-6.
https://psnet.ahrq.gov/issue/medication-safety-issue-brief-bar-c…
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psnet.ahrq.gov/node/38113/psn-pdf
February 28, 2009 - Prioritising the prevention of medication handling errors.
February 28, 2009
Bertsche T, Niemann D, Mayer Y, et al. Prioritising the prevention of medication handling errors. Pharm
World Sci. 2008;30(6):907-15. doi:10.1007/s11096-008-9250-3.
https://psnet.ahrq.gov/issue/prioritising-prevention-medication-handling-e…
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psnet.ahrq.gov/node/40751/psn-pdf
September 07, 2011 - Developing a programme for medication reconciliation at
the time of admission into hospital.
September 7, 2011
Manzorro ÁG, Zoni AC, Rieiro CR, et al. Developing a programme for medication reconciliation at the time
of admission into hospital. Int J Clin Pharm. 2011;33(4):603-9. doi:10.1007/s11096-011-9530-1.
http…
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psnet.ahrq.gov/node/38348/psn-pdf
December 30, 2014 - Implementing a bar-code medication administration
system.
December 30, 2014
Weber RJ. Implementing a Bar-Code Medication Administration System. Hosp Pharm. 2010;43(12):1016-
1022. doi:10.1310/hpj4312-1016.
https://psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
This commentary discusse…
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psnet.ahrq.gov/node/41617/psn-pdf
August 22, 2012 - Medical devices and patient safety.
August 22, 2012
Mattox E. Medical devices and patient safety. Crit Care Nurse. 2012;32(4):60-8. doi:10.4037/ccn2012925.
https://psnet.ahrq.gov/issue/medical-devices-and-patient-safety
This commentary discusses errors associated with medical device use in intensive care environmen…
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psnet.ahrq.gov/node/41275/psn-pdf
April 04, 2012 - Medication reconciliation campaign in a clinic for
homeless patients.
April 4, 2012
Moczygemba LR, Gatewood SBS, Kennedy AK, et al. Medication reconciliation campaign in a clinic for
homeless patients. Am J Health Syst Pharm. 2012;69(7):558, 560-2. doi:10.2146/ajhp110334.
https://psnet.ahrq.gov/issue/medication-re…
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psnet.ahrq.gov/node/47594/psn-pdf
March 17, 2023 - Prevention of perioperative medication errors.
March 17, 2023
Nanji K. UpToDate. March 7, 2023.
https://psnet.ahrq.gov/issue/prevention-perioperative-medication-errors
Perioperative adverse drug events are common and understudied. This review examines factors that
contribute to adverse drug events in the surgical …
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psnet.ahrq.gov/node/36267/psn-pdf
October 21, 2010 - Antiretroviral medication errors among hospitalized
patients with HIV infection.
October 21, 2010
Rastegar DA, Knight AM, Monolakis JS. Antiretroviral medication errors among hospitalized patients with
HIV infection. Clin Infect Dis. 2006;43(7):933-8.
https://psnet.ahrq.gov/issue/antiretroviral-medication-errors-a…
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psnet.ahrq.gov/node/37565/psn-pdf
February 27, 2008 - Effect of pharmacists on medication errors in an
emergency department.
February 27, 2008
Brown JN, Barnes CL, Beasley B, et al. Effect of pharmacists on medication errors in an emergency
department. Am J Health Syst Pharm. 2008;65(4):330-3. doi:10.2146/ajhp070391.
https://psnet.ahrq.gov/issue/effect-pharmacists-me…