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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.
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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
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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.
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Format: …
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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
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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
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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…
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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/…
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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/…
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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…
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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…
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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:…
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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://…
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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…
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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…
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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…
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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…
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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
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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
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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…
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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…