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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting
of Medications Used by Anesthesia
July 29, 2020
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications
Used by Anesthesia. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/issue/safeguarding-storage-drug-products
December 15, 2010 - Newspaper/Magazine Article
Safeguarding the storage of drug products.
Citation Text:
Safeguarding the storage of drug products. PA-PSRS Patient Saf Advis. 2010;7(2):46-51.
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psnet.ahrq.gov/issue/health-literacy
December 23, 2011 - Special or Theme Issue
Health Literacy.
Citation Text:
Health Literacy. J Gen Intern Med. 2006;21(8):806-899.
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psnet.ahrq.gov/issue/drug-shortages-obama-tries-prevent-emergencies
April 10, 2024 - Newspaper/Magazine Article
Drug shortages: Obama tries to prevent emergencies.
Citation Text:
Drug shortages: Obama tries to prevent emergencies. Neergaard L. San Francisco Chronicle; November 1, 2011:A6.
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psnet.ahrq.gov/issue/medication-assessment-one-determinant-falls-risk
July 24, 2013 - Newspaper/Magazine Article
Medication assessment: one determinant of falls risk.
Citation Text:
Medication assessment: one determinant of falls risk. PA-PSRS Patient Saf Advis. March 2008;5:16-18.
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psnet.ahrq.gov/issue/medication-reconciliation-getting-started-it
April 27, 2016 - Newspaper/Magazine Article
Medication reconciliation: getting started with IT.
Citation Text:
Medication reconciliation: getting started with IT. Lefeber J
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-28
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR. ISMP medication error report analysis. Hosp Pharm. 2010;43(8):618-620. doi:10.1310/hpj4308-618.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …
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psnet.ahrq.gov/web-mm/amphotericin-toxicity
April 01, 2014 - Amphotericin Toxicity
Citation Text:
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - Spotlight Case July 2008
Spotlight Case
Total Parenteral Nutrition, Multifarious Errors
*
*
Source and Credits
This presentation is based on the April 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph I. Boullata, PharmD, RPh, BCNSP…
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - 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/issue/safe-practice-environment-chapter-proposed-usp
May 02, 2018 - Newspaper/Magazine Article
Safe practice environment chapter proposed by USP.
Citation Text:
Safe practice environment chapter proposed by USP. ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.
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psnet.ahrq.gov/issue/fda-pharmacists-help-consumers-use-medicines-safely
September 02, 2016 - Fact Sheet/FAQs
FDA Pharmacists Help Consumers Use Medicines Safely.
Citation Text:
FDA Pharmacists Help Consumers Use Medicines Safely. Silver Spring, MD: United States Food and Drug Administration; October 31, 2014.
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psnet.ahrq.gov/issue/progress-preventing-name-confusion-errors
May 07, 2018 - Newspaper/Magazine Article
Progress with preventing name confusion errors.
Citation Text:
Progress with preventing name confusion errors. ISMP Medication Safety Alert! Acute Care Edition. August 9, 2007;12:1-3.
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psnet.ahrq.gov/issue/ismps-second-quarterwatch-report-shows-sharp-increase-reports-serious-adverse-drug-events
June 10, 2018 - Newspaper/Magazine Article
ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events.
Citation Text:
ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events. ISMP Medication Safety Alert! Acute Care Editi…
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psnet.ahrq.gov/issue/prescription-infrastructre-are-we-ready-eprescribing
August 17, 2011 - Book/Report
The Prescription Infrastructre: Are We Ready for ePrescribing?
Citation Text:
The Prescription Infrastructre: Are We Ready for ePrescribing? Sarasohn-Kahn J, Holt M. Oakland, CA: California Healthcare Foundation; 2006. ISBN 1933795026.
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