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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/34039/psn-pdf
June 16, 2010 - Spike in fatal medication errors at the beginning of each
month.
June 16, 2010
Phillips DP, Jarvinen JR, Phillips RR. A spike in fatal medication errors at the beginning of each month.
Pharmacotherapy. 2005;25(1):1-9.
https://psnet.ahrq.gov/issue/spike-fatal-medication-errors-beginning-each-month
This study found…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/50930/psn-pdf
February 21, 2020 - workarounds should be in place prior to implementation to ensure a safe and
https://psnet.ahrq.gov/issue/community-pharmacy-survey-patient-safety-culture … -2019-user-comparative-database-report
https://psnet.ahrq.gov/issue/community-pharmacy-medication-review-death-and-re-admission-after-hospital-discharge
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Crossed Coverage
February 1, 2007
Kayser SR. Crossed Coverage. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/crossed-coverage
The Case
A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation
evaluation. She had already undergone multiple surgeries, including…
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psnet.ahrq.gov/node/45338/psn-pdf
July 20, 2016 - Understanding models of error and how they apply in
clinical practice.
July 20, 2016
Garfield S, Franklin BD. Pharm J. June 14, 2016.
https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice
Human error and fallibility are a part of health care delivery that can be exacerbated b…
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psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors
May 02, 2018 - Newspaper/Magazine Article
Misprogramming PCA concentration leads to dosing errors.
Citation Text:
Misprogramming PCA concentration leads to dosing errors. ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
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psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
September 09, 2015 - Newspaper/Magazine Article
Reminder: pay attention to the appearance of your medicines.
Citation Text:
Reminder: pay attention to the appearance of your medicines. ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
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psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
May 11, 2014 - Commentary
Implementing a bar-code medication administration system.
Citation Text:
Weber RJ. Implementing a Bar-Code Medication Administration System. Hosp Pharm. 2010;43(12):1016-1022. doi:10.1310/hpj4312-1016.
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psnet.ahrq.gov/issue/fluorouracil-error-ends-tragically-application-lessons-learned-will-save-lives
June 10, 2018 - Newspaper/Magazine Article
Fluorouracil error ends tragically, but application of lessons learned will save lives.
Citation Text:
Fluorouracil error ends tragically, but application of lessons learned will save lives. ISMP Medication Safety Alert! Acute care edition. September 20, 2007. …
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psnet.ahrq.gov/issue/errors-injectable-medications-unlabeled-syringes-are-surprisingly-common
December 27, 2018 - Newspaper/Magazine Article
Errors with injectable medications: unlabeled syringes are surprisingly common!
Citation Text:
Errors with injectable medications: unlabeled syringes are surprisingly common! ISMP Medication Safety Alert! Acute care edition. November 15, 2007.
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psnet.ahrq.gov/issue/technical-patient-safety-solutions-medicines-reconciliation-admission-adults-hospital
October 27, 2021 - Organizational Policy/Guidelines
Technical patient safety solutions for medicines reconciliation on admission of adults to hospital.
Citation Text:
Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. Manchester, UK: National Institute…
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psnet.ahrq.gov/issue/err-human-patient-misinterpretations-prescription-drug-label-instructions
February 28, 2011 - Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies … January 21, 2009
View More
See More About The Topic
Community Pharmacy
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psnet.ahrq.gov/node/47097/psn-pdf
June 26, 2018 - indicators of opioid misuse (e.g., obtaining opioids from more
than five prescribers or more than five pharmacies
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - wait times and errors related to illegible handwriting by transmitting prescriptions electronically to pharmacies … make errors initially and must use the e-prescribing system routinely to gain experience with it
Some pharmacies … Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies
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psnet.ahrq.gov/node/39456/psn-pdf
May 04, 2010 - A prior study found that translated drug
labels are available in many pharmacies, but this study found
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psnet.ahrq.gov/issue/themed-issue-innovations-medication-safety
August 30, 2017 - Related Resources
Errors originating in hospital and health-system outpatient pharmacies … December 29, 2014
Communicating medication changes to community pharmacy post-discharge
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psnet.ahrq.gov/node/47579/psn-pdf
December 12, 2018 - indications on prescriptions, ensuring a readily available
and accurate medication list, notifying pharmacies
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - with reviewing naloxone prescriptions and providing education for patients within the health system's pharmacies … , but no such mechanism existed for "outside pharmacies." … a need for alternative, proactive education plans for situations in which prescriptions are sent to pharmacies … 2022
WebM&M Cases
Medication Errors in Retail Pharmacies
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psnet.ahrq.gov/node/41863/psn-pdf
November 21, 2012 - compared the accuracy of patient-reported
medication lists with a "gold standard" list compiled from pharmacies