-
psnet.ahrq.gov/issue/medication-errors-care-transition-trauma-patients
September 02, 2020 - Study
Medication errors in the care transition of trauma patients
Citation Text:
Martín Mª ÁP, García MM, Silveira ED, et al. Medication errors in the care transition of trauma patients. Eur J Clin Pharmacol. 2019;75(12):1739-1746. doi:10.1007/s00228-019-02757-3.
Copy Citation
Form…
-
psnet.ahrq.gov/issue/pharmacists-interventions-prescribing-errors-hospital-discharge-observational-study-context
October 16, 2012 - Study
Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.
Citation Text:
Abdel-Qader DH, Harper L, Cantrill JA, et al. Pharmacists' interventions in prescribing erro…
-
psnet.ahrq.gov/issue/effect-bar-code-assisted-medication-administration-medication-error-rates-adult-medical
July 23, 2010 - Study
Effect of bar-code–assisted medication administration on medication error rates in an adult medical intensive care unit.
Citation Text:
DeYoung JL, Vanderkooi ME, Barletta JF. Effect of bar-code-assisted medication administration on medication error rates in an adult medical inte…
-
psnet.ahrq.gov/issue/pediatric-medication-safety-considerations-pharmacists-adult-hospital-setting
January 29, 2020 - Commentary
Pediatric medication safety considerations for pharmacists in an adult hospital setting.
Citation Text:
Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/aj…
-
psnet.ahrq.gov/issue/implementation-and-sustainability-medication-reconciliation-toolkit-mixed-methods-evaluation
May 19, 2021 - Study
Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.
Citation Text:
Stolldorf DP, Mixon AS, Auerbach AD, et al. Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation. Am J Health Syst Ph…
-
psnet.ahrq.gov/issue/use-prospective-risk-analysis-method-improve-safety-cancer-chemotherapy-process
May 29, 2019 - Study
Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process.
Citation Text:
Bonnabry P, Cingria L, Ackermann M, et al. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care…
-
psnet.ahrq.gov/issue/putting-knowledge-practice-does-information-adverse-drug-interactions-influence-peoples
June 14, 2023 - Study
Putting knowledge into practice: does information on adverse drug interactions influence people's dosing behaviour?
Citation Text:
Dohle S, Dawson IGJ. Putting knowledge into practice: Does information on adverse drug interactions influence people's dosing behaviour? Br J Health Ps…
-
psnet.ahrq.gov/issue/prospective-study-multisite-spread-medication-safety-intervention-factors-common-hospitals
April 24, 2018 - Study
Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals with improved outcomes.
Citation Text:
Kaplan HC, Goldstein SL, Rubinson C, et al. Prospective study of the multisite spread of a medication safety intervention: factors commo…
-
psnet.ahrq.gov/issue/frequency-hiv-related-medication-errors-and-associated-risk-factors-hospitalized-patients
April 24, 2018 - Study
Frequency of HIV-related medication errors and associated risk factors in hospitalized patients.
Citation Text:
Pastakia SD, Corbett AH, Raasch RH, et al. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Ann Pharmacother. 2008;42(4)…
-
psnet.ahrq.gov/issue/machine-learning-based-clinical-predictive-tool-identify-patients-high-risk-medication-errors
March 29, 2012 - Study
A machine learning-based clinical predictive tool to identify patients at high risk of medication errors.
Citation Text:
Abdo A, Gallay L, Vallecillo T, et al. A machine learning-based clinical predictive tool to identify patients at high risk of medication errors. Sci Rep. 2024;14…
-
psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - Good Night's Sleep Gone Wrong
February 1, 2016
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
The Case
A 64-year-old woman came to the emergency department complaining of cough and shortness of breath,
along with an…
-
psnet.ahrq.gov/node/851054/psn-pdf
June 28, 2023 - or interventions related to psychiatric medication safety in
primary care (e.g., general practice, community … pharmacy, long-term care).
-
psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
-
psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - systems—CPOE systems used
primarily in outpatient practices that allow direct transmittal of prescriptions to pharmacies—have
-
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
-
psnet.ahrq.gov/node/36699/psn-pdf
March 28, 2011 - Hospital staff should use more than one method to detect
adverse events and potential adverse events: incident
reporting, pharmacist surveillance and local real-time
record review may all have a place.
March 28, 2011
Olsen S, Neale G, Schwab K, et al. Hospital staff should use more than one method to detect advers…
-
psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - also include Elements to Assure Safe Use, which may require prescribers to have specific training, pharmacies
-
psnet.ahrq.gov/issue/electronic-medical-record-based-interventions-encourage-opioid-prescribing-best-practices
September 01, 2021 - Study
Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.
Citation Text:
Smalley CM, Willner MA, Muir MKR, et al. Electronic medical record-based interventions to encourage opioid prescribing best practices in the emer…
-
psnet.ahrq.gov/issue/avoiding-med-wreck-structured-medication-reconciliation-framework-and-standardized-auditing
May 12, 2021 - Study
Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources.
Citation Text:
Elbeddini A, Almasalkhi S, Prabaharan T, et al. Avoiding a Med-Wreck: a structured medication …
-
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