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9561. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49645/psn-pdf
      February 01, 2012 - electronic media, of prescriptions or prescription-related information from a prescriber (physician, nurse … psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references Case & Commentary- Part 2: The clinic nurse … Unfortunately, the clinic nurse entered the atenolol without checking the name and date of birth on … In addition, the system allowed the nurse to prescribe on behalf of the doctor and transmit without … A return receipt of prescriptions that reach the pharmacy would also have alerted the nurse that two

9562. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854897/psn-pdf
      October 31, 2023 - This order, representing about 12 mg/kg, was filled by pharmacy staff and administered by a nurse who … weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication A few minutes later, the supervising senior pediatric nurse … Pharmacy staff subsequently dispensed this dose, and it was administered by a nurse who was new to the … “hole” in this case was limited oversight by the attending physician and the supervising pediatric nurse … and provide appropriate oversight of inexperienced trainees by an attending physician or supervising nurse

9563. Survival from in-hospital cardiac arrest during nights and weekends. | PSNet
      psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-during-nights-and-weekends
      February 18, 2011 - Study Survival from in-hospital cardiac arrest during nights and weekends. Citation Text: Peberdy MA, Ornato JP, Larkin L, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-92. doi:10.1001/jama.299.7.785. Copy Citation Format: …

9564. Preoperative multidisciplinary team huddle improves communication and safety for unscheduled cesarean deliveries: a system redesign using improvement science. | PSNet
      psnet.ahrq.gov/issue/preoperative-multidisciplinary-team-huddle-improves-communication-and-safety-unscheduled
      October 19, 2022 - Study Preoperative multidisciplinary team huddle improves communication and safety for unscheduled cesarean deliveries: a system redesign using improvement science. Citation Text: Girnius A, Snyder C, Czarny H, et al. Preoperative multidisciplinary team huddle improves communication and …

9565. National Action Plan for Adverse Drug Event Prevention. | PSNet
      psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention
      October 16, 2013 - Book/Report National Action Plan for Adverse Drug Event Prevention. Citation Text: National Action Plan for Adverse Drug Event Prevention. Washington, DC: Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services; September 2014. Copy Cita…

9566. Intraoperative patient information handover between anesthesia providers. | PSNet
      psnet.ahrq.gov/issue/intraoperative-patient-information-handover-between-anesthesia-providers
      November 24, 2021 - Study Intraoperative patient information handover between anesthesia providers. Citation Text: Choromanski D, Frederick J, McKelvey GM, et al. Intraoperative patient information handover between anesthesia providers. J Biomed Res. 2014;28(5):383-387. doi:10.7555/JBR.28.20140001. Copy C…

9567. Retrospective analysis of medication incidents reported using an on-line reporting system. | PSNet
      psnet.ahrq.gov/issue/retrospective-analysis-medication-incidents-reported-using-line-reporting-system
      April 01, 2015 - Study Retrospective analysis of medication incidents reported using an on-line reporting system. Citation Text: Ashcroft DM, Cooke J. Retrospective analysis of medication incidents reported using an on-line reporting system. Pharmacy World & Science. 2006;28(6). doi:10.1007/s11096-006-…

9568. Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011–2015. | PSNet
      psnet.ahrq.gov/issue/declines-opioid-prescribing-after-private-insurer-policy-change-massachusetts-2011-2015
      October 19, 2022 - Government Resource Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011–2015. Citation Text: García MC, Dodek AB, Kowalski T, et al. Declines in Opioid Prescribing After a Private Insurer Policy Change - Massachusetts, 2011-2015. MMWR Morb Mortal Wkly…

9569. National Action Plan for Adverse Drug Event Prevention: recommendations for safer outpatient opioid use. | PSNet
      psnet.ahrq.gov/issue/national-action-plan-adverse-drug-event-prevention-recommendations-safer-outpatient-opioid
      August 05, 2015 - Commentary National Action Plan for Adverse Drug Event Prevention: recommendations for safer outpatient opioid use. Citation Text: Ducoffe AR, York A, Hu DJ, et al. National Action Plan for Adverse Drug Event Prevention: Recommendations for Safer Outpatient Opioid Use. Pain Med. 2016;17(…

9570. Assessment of a simulated case-based measurement of physician diagnostic performance. | PSNet
      psnet.ahrq.gov/issue/assessment-simulated-case-based-measurement-physician-diagnostic-performance
      May 20, 2019 - Study Assessment of a simulated case-based measurement of physician diagnostic performance. Citation Text: Chatterjee S, Desai S, Manesh R, et al. Assessment of a Simulated Case-Based Measurement of Physician Diagnostic Performance. JAMA Netw Open. 2019;2(1):e187006. doi:10.1001/jamanetw…

9571. Does the concept of safety culture help or hinder systems thinking in safety? | PSNet
      psnet.ahrq.gov/issue/does-concept-safety-culture-help-or-hinder-systems-thinking-safety
      October 12, 2011 - Commentary Does the concept of safety culture help or hinder systems thinking in safety? Citation Text: Reiman T, Rollenhagen C. Does the concept of safety culture help or hinder systems thinking in safety? Accid Anal Prev. 2014;68(July):5-15. doi:10.1016/j.aap.2013.10.033. Copy Citati…

9572. Overview of Methicillin-Resistant Staphylococcus aureus (MRSA)-Related Adult Inpatient Stays, 2016–2021. HCUP Statistical Brief #315. | PSNet
      psnet.ahrq.gov/issue/overview-methicillin-resistant-staphylococcus-aureus-mrsa-related-adult-inpatient-stays-2016
      December 11, 2024 - Book/Report Overview of Methicillin-Resistant Staphylococcus aureus (MRSA)-Related Adult Inpatient Stays, 2016–2021. HCUP Statistical Brief #315. Citation Text: Miller MA, Owens P, Kim J, et al. Overview Of Methicillin-Resistant Staphylococcus Aureus (Mrsa)-Related Adult Inpatient Stays,…

9573. Beyond the prescription: medication monitoring and adverse drug events in older adults. | PSNet
      psnet.ahrq.gov/issue/beyond-prescription-medication-monitoring-and-adverse-drug-events-older-adults
      August 04, 2021 - Commentary Beyond the prescription: medication monitoring and adverse drug events in older adults. Citation Text: Steinman MA, Handler S, Gurwitz JH, et al. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc. 2011;59(8):1513-1520. d…

9574. Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness. | PSNet
      psnet.ahrq.gov/issue/patient-assessments-hypothetical-medical-error-effects-health-outcome-disclosure-and-staff
      February 24, 2011 - Study Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness. Citation Text: Cleopas A, Villaveces A, Charvet A, et al. Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff re…

9575. Wear face masks with no metal during MRI exams. | PSNet
      psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams
      April 08, 2020 - Press Release/Announcement Wear face masks with no metal during MRI exams. Citation Text: Wear face masks with no metal during MRI exams. FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020. Copy Citation …

9576. Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies. | PSNet
      psnet.ahrq.gov/issue/maintaining-perioperative-safety-uncertain-times-covid-19-pandemic-response-strategies
      December 23, 2020 - Commentary Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies. Citation Text: Mazzola SM, Grous C. Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies. AORN J. 2020;112(4):397-405. doi:10.1002/aorn.13195. Co…

9577. Value assessment of deprescribing interventions: suggestions for improvement. | PSNet
      psnet.ahrq.gov/issue/value-assessment-deprescribing-interventions-suggestions-improvement
      August 04, 2021 - Commentary Value assessment of deprescribing interventions: suggestions for improvement. Citation Text: Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: suggestions for improvement. J Am Geriatr Soc. 2023;71(6):2023-2027. doi:10.1111/jgs.18298. Copy C…

9578. Using in situ simulation to identify latent safety threats in emergency medicine: a systematic review. | PSNet
      psnet.ahrq.gov/issue/using-situ-simulation-identify-latent-safety-threats-emergency-medicine-systematic-review
      November 03, 2015 - Review Using in situ simulation to identify latent safety threats in emergency medicine: a systematic review. Citation Text: Grace MA, O'Malley R. Using in situ simulation to identify latent safety threats in emergency medicine: a systematic review. Simul Healthc. 2023;19(4):243-253. doi…

9579. Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. | PSNet
      psnet.ahrq.gov/issue/effect-multifaceted-clinical-pharmacist-intervention-medication-safety-after-hospitalization
      April 28, 2021 - Study Emerging Classic Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. Citation Text: Gurwitz JH, Kapoor A, Garber L, et al. Effect of …

9580. The impact of the built environment on patient falls in hospital rooms: an integrative review. | PSNet
      psnet.ahrq.gov/issue/impact-built-environment-patient-falls-hospital-rooms-integrative-review
      July 27, 2022 - Review The impact of the built environment on patient falls in hospital rooms: an integrative review. Citation Text: Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms: an integrative review. J Patient Saf. 2021;17(4):273-281. doi…