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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49470/psn-pdf
    December 01, 2004 - a medication for Alzheimer's disease), 4 mg twice daily to be increased to 8 mg twice daily in one month … Patients in the post-discharge research studies were followed for, at most, one month.
  2. psnet.ahrq.gov/web-mm/undetected-foreign-object
    April 24, 2018 - reported that introduction of data matrix–labeled sponges eliminated cotton sponge RSIs over an 18-month
  3. psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - SPOTLIGHT CASE Anemia and Delayed Colon Cancer Diagnosis Citation Text: Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  4. psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
    March 21, 2009 - distribution program in one health system, the number of naloxone prescriptions increased from 4.5 per month … to 46 prescriptions per month. 6   Even though it is the legal duty of a pharmacist to provide patient
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49508/psn-pdf
    January 01, 2007 - https://psnet.ahrq.gov/web-mm/language-barrier The Case A previously healthy 10-month-old girl was … The parents administered the medication at home and, within 15 minutes, the 10-month-old vomited twice
  6. psnet.ahrq.gov/issue/elucidating-reasons-resident-underutilization-electronic-adverse-event-reporting
    November 21, 2021 - Study Elucidating reasons for resident underutilization of electronic adverse event reporting. Citation Text: Hatoun J, Suen W, Liu C, et al. Elucidating Reasons for Resident Underutilization of Electronic Adverse Event Reporting. Am J Med Qual. 2016;31(4):308-314. doi:10.1177/1062860615…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35275/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 This monthly selection of medication error reports provides examples from the field of potential errors and helpful tips on how to avoid similar mistakes. https://psnet.ahrq.gov/issue/…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38933/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-38 This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing. https://psnet.ahrq.gov/…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37897/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-26 This monthly selection of medication error reports includes examples of look-alike/sound-alike medications and a discussion of immunosuppressant dosing errors. https://psnet.ahrq.go…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36257/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-7 This monthly selection of medication error reports provides examples of problems related to poorly scanned pharmacy orders, ambiguous labeling, and abbreviation use. https://psnet.ah…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35560/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-2 This monthly selection of medication error reports provides examples of problems with neuromuscular blocking agents, confusion with drug names, and unclear labeling practices. https:…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36840/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-11 This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values. https://…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36071/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-6 This monthly selection of medication error reports provides examples of nimodipine administration mishaps, a lithium overdose, and suggested adopted drug names for review. https://ps…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38266/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Smetzer JL; Cohen MR. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-31 This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephed…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37084/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-15 This monthly selection of medication error reports discusses product name confusion, an unsafe process for outdated drug replacement, and smart pump dose administration problems. ht…
  16. psnet.ahrq.gov/issue/prevention-retained-surgical-sponges-decision-analytic-model-predicting-relative-cost
    January 04, 2010 - Study Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Citation Text: Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surger…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49458/psn-pdf
    September 01, 2004 - Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49665/psn-pdf
    September 01, 2012 - reported that introduction of data matrix–labeled sponges eliminated cotton sponge RSIs over an 18-month
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33941/psn-pdf
    October 11, 2016 - BMJ Quality & Safety. October 11, 2016 Franklin BD, Thomas E, eds. BMJ Publishing Group Ltd and the Health Foundation. ISSN: 2044-5415. https://psnet.ahrq.gov/issue/bmj-quality-safety A monthly peer-reviewed journal that reports research, initiatives, and viewpoints in the growing area of safety and quality improv…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37461/psn-pdf
    May 11, 2014 - ISMP medication error report analysis. May 11, 2014 Cohen MR; Smetzer JL. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-20 This monthly selection of medication error reports discusses problems related to a lack of standardization in IV dosing and talc misadministration. https://psnet.ahrq.gov…

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