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1641. How useful are voluntary medication error reports? The case of warfarin-related medication errors. | PSNet
      psnet.ahrq.gov/issue/how-useful-are-voluntary-medication-error-reports-case-warfarin-related-medication-errors
      May 27, 2011 - outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid … analgesics.

1642. Medication discrepancies upon hospital to skilled nursing facility transitions. | PSNet
      psnet.ahrq.gov/issue/medication-discrepancies-upon-hospital-skilled-nursing-facility-transitions
      July 20, 2011 - Most concerning, many discrepancies involved high-risk medications such as opioid analgesics, anticoagulants

1643. Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes. | PSNet
      psnet.ahrq.gov/issue/medicare-and-medicaid-programs-and-childrens-health-insurance-program-hospital-inpatient
      November 23, 2015 - outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid … analgesics.

1644. Patient safety and suicide prevention in mental health services: time for a new paradigm? | PSNet
      psnet.ahrq.gov/issue/patient-safety-and-suicide-prevention-mental-health-services-time-new-paradigm
      April 19, 2023 - Commentary Patient safety and suicide prevention in mental health services: time for a new paradigm? Citation Text: Quinlivan L, Littlewood DL, Webb RT, et al. Patient safety and suicide prevention in mental health services: time for a new paradigm? J Mental Health. 2020;29(1):1-5. doi…

1645. Mandating limits on workload, duty, and speed in radiology. | PSNet
      psnet.ahrq.gov/issue/mandating-limits-workload-duty-and-speed-radiology
      August 11, 2021 - Review Mandating limits on workload, duty, and speed in radiology. Citation Text: Alexander R, Waite S, Bruno MA, et al. Mandating limits on workload, duty, and speed in radiology. Radiology. 2022:212631. doi:10.1148/radiol.212631. Copy Citation Format: DOI Google Scholar B…

1646. Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip). | PSNet
      psnet.ahrq.gov/issue/medication-errors-resulting-confusion-between-risperidone-risperdal-and-ropinirole-requip
      December 16, 2020 - Press Release/Announcement Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip). Citation Text: Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip). MedWatch Safety Alert, FDA Drug Safety Com…

1647. As she lay dying: how I fought to stop medical errors from killing my mom. | PSNet
      psnet.ahrq.gov/issue/she-lay-dying-how-i-fought-stop-medical-errors-killing-my-mom
      December 19, 2012 - Commentary As she lay dying: how I fought to stop medical errors from killing my mom. Citation Text: Welch JR. As she lay dying: how I fought to stop medical errors from killing my mom. Health Aff (Millwood). 2012;31(12):2817-2820. doi:10.1377/hlthaff.2012.0833. Copy Citation For…

1648. Analysis of risk factors for adverse drug events in critically ill patients. | PSNet
      psnet.ahrq.gov/issue/analysis-risk-factors-adverse-drug-events-critically-ill-patients
      October 26, 2010 - Study Analysis of risk factors for adverse drug events in critically ill patients. Citation Text: Kane-Gill SL, Kirisci L, Verrico MM, et al. Analysis of risk factors for adverse drug events in critically ill patients*. Crit Care Med. 2012;40(3):823-8. doi:10.1097/CCM.0b013e318236f473.…

1649. Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. | PSNet
      psnet.ahrq.gov/issue/patient-errors-use-injectable-antidiabetic-medications-need-improved-clinic-based-education
      March 17, 2021 - Commentary Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. Citation Text: Wei ET, Koh E, Kelly MS, et al. Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. J Am Pharm Assoc (…

1650. Toward the development of the perfect medical team: critical components for adaptation. | PSNet
      psnet.ahrq.gov/issue/toward-development-perfect-medical-team-critical-components-adaptation
      February 09, 2022 - Review Emerging Classic Toward the development of the perfect medical team: critical components for adaptation. Citation Text: Gregory ME, Hughes AM, Benishek LE, et al. Toward the development of the perfect medical team: critical components for adaptation. J Pa…

1651. Do HSMRs really measure patient safety?  | PSNet
      psnet.ahrq.gov/issue/do-hsmrs-really-measure-patient-safety
      June 22, 2009 - Special or Theme Issue Do HSMRs really measure patient safety?  Citation Text: Do HSMRs really measure patient safety?  Leatt P; Wen E; Sandoval C; Zelmer J; Webster G; Jarman B; McKinley J; Gibson D; Ardal S; Zahn C; Baker M; MacNaughton J; Flemming C; Bell R; Figler S; Brien SE; Gh…

1652. Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. | PSNet
      psnet.ahrq.gov/issue/goals-and-priorities-health-care-organizations-improve-safety-using-health-it-revised-report
      May 13, 2015 - Book/Report Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. Citation Text: Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. Graber ML, Bailey R, Johnston D. RTI International; Washi…

1653. Variation in hospital mortality associated with inpatient surgery. | PSNet
      psnet.ahrq.gov/issue/variation-hospital-mortality-associated-inpatient-surgery
      August 02, 2015 - Study Classic Variation in hospital mortality associated with inpatient surgery. Citation Text: Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-75. doi:10.1056/NEJMsa090304…

1654. From HRO to HERO: making health equity a core system capability. | PSNet
      psnet.ahrq.gov/issue/hro-hero-making-health-equity-core-system-capability
      September 30, 2020 - Commentary From HRO to HERO: making health equity a core system capability. Citation Text: Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability. Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020. Copy Citation Format: …

1655. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. | PSNet
      psnet.ahrq.gov/issue/lost-translation-challenges-and-opportunities-physician-physician-communication-during
      April 12, 2011 - Study Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Citation Text: Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoff…

1656. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45126/psn-pdf
      December 22, 2018 - monitoring programs are intended to identify high-risk prescribing and patient behaviors associated with opioids

1657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46893/psn-pdf
      March 21, 2018 - vital-signs-trends-emergency-department-visits-suspected-opioid-overdoses-united-states-july https://psnet.ahrq.gov/issue/cdc-guideline-prescribing-opioids-chronic-pain-united-states

1658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46186/psn-pdf
      August 02, 2017 - new-persistent-opioid-use-after-minor-and-major-surgical-procedures-us-adults https://psnet.ahrq.gov/issue/opioids-chronic-noncancer-pain-position-paper-american-academy-neurology

1659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47333/psn-pdf
      October 10, 2018 - association-household-opioid-availability-and-prescription-opioid-initiation-among-household https://psnet.ahrq.gov/issue/cdc-guideline-prescribing-opioids-chronic-pain-united-states

1660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44819/psn-pdf
      June 21, 2016 - More than 90% of patients were prescribed opioids following such events, and within 2 years up to 17%