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psnet.ahrq.gov/node/39477/psn-pdf
April 28, 2010 - Effects of an adverse-drug-event alert system on cost and
quality outcomes in community hospitals.
April 28, 2010
Piontek F, Kohli R, Conlon P, et al. Effects of an adverse-drug-event alert system on cost and quality
outcomes in community hospitals. Am J Health Syst Pharm. 2010;67(8):613-20. doi:10.2146/ajhp090056.…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors
April 1, 2013
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
Case Objectives
Define parenteral nutrition (PN).
Describe the PN-use process.
Identify …
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/863212/psn-pdf
February 28, 2024 - common in community settings including primary
care, general practice, mental health services, and community … pharmacy.
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/issue/community-acquired-and-hospital-acquired-medication-harm-among-older-inpatients-and-impact
August 28, 2024 - Study
Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention.
Citation Text:
Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm among older inpatients an…
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psnet.ahrq.gov/issue/assessing-potential-adoption-and-usefulness-concurrent-action-oriented-electronic-adverse
October 01, 2014 - Study
Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting.
Citation Text:
Mull HJ, Rosen AK, Shimada SL, et al. Assessing the potential adoption and usefulness of concurrent, action-ori…
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psnet.ahrq.gov/issue/rural-va-multi-center-medication-reconciliation-quality-improvement-study-r-va-marquis
September 30, 2020 - Study
The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).
Citation Text:
Presley CA, Wooldridge KT, Byerly SH, et al. The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS). Am J Health Syst Pharm. 2020;77(2)…
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psnet.ahrq.gov/issue/some-version-most-time-surgical-safety-checklist-patient-safety-and-everyday-experience
December 15, 2021 - Study
"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.
Citation Text:
Hammond Mobilio M, Paradis E, Moulton C-A. “Some version, most of the time”: The surgical safety checklist, patient safety, and the eve…
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psnet.ahrq.gov/issue/improved-medication-management-introduction-perioperative-and-prescribing-pharmacist-service
August 05, 2020 - Study
Improved medication management with introduction of a perioperative and prescribing pharmacist service.
Citation Text:
Nguyen AD, Lam A, Banakh I, et al. Improved medication management with introduction of a perioperative and prescribing pharmacist service. J Pharm Pract. 2020;33(3…
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psnet.ahrq.gov/issue/chemotherapy-regimen-checks-performed-pharmacists-contribute-safe-administration-chemotherapy
April 01, 2010 - Study
Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy.
Citation Text:
Suzuki S, Chan A, Nomura H, et al. Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy. J Oncol Pract. 2017;23(1…
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psnet.ahrq.gov/issue/economic-outcomes-associated-safety-interventions-pharmacist-adjudicated-prior-authorization
September 23, 2020 - Study
Economic outcomes associated with safety interventions by a pharmacist–adjudicated prior authorization consult service.
Citation Text:
Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a Pharmacist-Adjudicated Prior Authorization Consult …
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psnet.ahrq.gov/issue/exploring-pharmacist-experiences-delivering-individualised-prescribing-error-feedback-acute
May 30, 2016 - Study
Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting.
Citation Text:
Lloyd M, Watmough SD, O'Brien S, et al. Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospita…
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psnet.ahrq.gov/issue/insulin-pump-associated-adverse-events-qualitative-descriptive-study-clinical-consequences
May 19, 2018 - Study
Insulin pump-associated adverse events: a qualitative descriptive study of clinical consequences and potential root causes.
Citation Text:
Estock JL, Codario RA, Keddem S, et al. Insulin pump-associated adverse events: a qualitative descriptive study of clinical consequences and po…
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psnet.ahrq.gov/issue/antibiotic-prescribing-errors-patients-discharged-pediatric-emergency-department
September 22, 2021 - Study
Antibiotic prescribing errors in patients discharged from the pediatric emergency department.
Citation Text:
LaScala EC, Monroe AK, Hall GA, et al. Antibiotic prescribing errors in patients discharged from the pediatric emergency department. Pediatr Emerg Care. 2022;38(1):e387-e392…
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psnet.ahrq.gov/issue/adverse-drug-events-caused-serious-medication-administration-errors
December 19, 2009 - Study
Adverse drug events caused by serious medication administration errors.
Citation Text:
Kale A, Keohane C, Maviglia SM, et al. Adverse drug events caused by serious medication administration errors. BMJ Qual Saf. 2012;21(11):933-8. doi:10.1136/bmjqs-2012-000946.
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psnet.ahrq.gov/issue/usage-and-accuracy-medication-data-nationwide-health-information-exchange-quebec-canada
June 17, 2020 - Study
Usage and accuracy of medication data from nationwide health information exchange in Quebec, Canada.
Citation Text:
Motulsky A, Weir DL, Couture I, et al. Usage and accuracy of medication data from nationwide health information exchange in Quebec, Canada. J Am Med Inform Assoc. 201…
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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