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psnet.ahrq.gov/node/40586/psn-pdf
March 21, 2017 - Adopting real-time surveillance dashboards as a
component of an enterprisewide medication safety
strategy.
March 21, 2017
Waitman LR, Phillips IE, McCoy AB, et al. Adopting real-time surveillance dashboards as a component of
an enterprisewide medication safety strategy. Jt Comm J Qual Patient Saf. 2011;37(7):326-3…
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psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors
June 16, 2019 - Meeting/Conference Proceedings
Proceedings of a summit on preventing patient harm and death from IV medication errors.
Citation Text:
Proceedings of a summit on preventing patient harm and death from i.v. medication errors. doi:10.2146/ajhp080406.
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DO…
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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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
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - Staggered Sensitivity Results
March 1, 2007
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results
The Case
A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck
dissection, and pectoralis fla…
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psnet.ahrq.gov/primers-0
March 15, 2025 - Home Nursing
(1)
Medical/Surgical Nursing
(3)
Pharmacy
(6)
Community … Pharmacy
(3)
Hospital Pharmacy
(4)
Error Types
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psnet.ahrq.gov/node/49708/psn-pdf
May 01, 2014 - information with at
least one other reliable resource (for example, drug vials, patient medication lists, a community … pharmacy,
a primary care physician, or a government medication database).(11) At a minimum, medication
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation
Citation Text:
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/innovation/assessing-impact-virtual-medication-history-technicians-medication-reconciliation
December 01, 2021 - EMERGING INNOVATIONS
Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.
Citation Text:
Gadallah A, McGinnis B, Nguyen B, et al. Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies. Int J C…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-7
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-34
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-15
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - Interviewing family members and contacting primary care physician offices and local pharmacies may improve
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psnet.ahrq.gov/node/50697/psn-pdf
November 27, 2019 - Cardiac Arrest in a Woman with UTI: A Case of QT
Prolongation
November 27, 2019
Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
The Case
A 36-year-old woman with a history of dep…
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-17
January 17, 2018 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR; Smetzer JL.
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psnet.ahrq.gov/issue/extra-dose-safety
June 16, 2019 - Newspaper/Magazine Article
An extra dose of safety.
Citation Text:
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…