-
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.
Copy Citation
Format:
Google Scholar BibTeX En…
-
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…
-
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…
-
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…
-
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
-
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…
-
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 …
-
psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - Interviewing family members and contacting primary care physician offices and local pharmacies may improve
-
psnet.ahrq.gov/issue/addressing-opioid-crisis-united-states
November 18, 2011 - Book/Report
Addressing the Opioid Crisis in the United States.
Citation Text:
Addressing the Opioid Crisis in the United States. Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April 2016.
Copy Citation
Save
Save to y…
-
psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
June 10, 2018 - Newspaper/Magazine Article
ISMP updates its list of drug name pairs with Tall man letters.
Citation Text:
ISMP updates its list of drug name pairs with Tall man letters. ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.
Copy Citation
Save
…
-
psnet.ahrq.gov/issue/medical-abbreviations-have-contradictory-or-ambiguous-meanings
November 18, 2020 - Newspaper/Magazine Article
Medical abbreviations that have contradictory or ambiguous meanings.
Citation Text:
Medical abbreviations that have contradictory or ambiguous meanings. Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020;25(2):1-5.
Copy Citatio…
-
psnet.ahrq.gov/issue/use-directed-can-cause-confusion-both-patients-and-practitioners
August 24, 2016 - Newspaper/Magazine Article
"Use as directed" can cause confusion for both patients and practitioners.
Citation Text:
"Use as directed" can cause confusion for both patients and practitioners. ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3.
Copy Citation
…
-
psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
August 12, 2020 - Book/Report
Effective Reporting Could Improve Safe Use of Electronic Health Records.
Citation Text:
Effective Reporting Could Improve Safe Use of Electronic Health Records. Philadelphia, PA: Pew Charitable Trusts; March 2020.
Copy Citation
Save
Save to your libr…
-
psnet.ahrq.gov/issue/raising-index-suspicion-red-flags-represent-credible-threats-patient-safety
February 13, 2019 - Newspaper/Magazine Article
Raising the index of suspicion: red flags that represent credible threats to patient safety.
Citation Text:
Raising the index of suspicion: red flags that represent credible threats to patient safety. ISMP Medication Safety Alert! Acute Care Edition. July 26, 2…
-
psnet.ahrq.gov/issue/mistake-proofing-design-health-care-processes
December 18, 2008 - Book/Report
Mistake-Proofing the Design of Health Care Processes.
Citation Text:
Mistake-Proofing the Design of Health Care Processes. Grout JR. Rockville, MD: Agency for Healthcare Research and Quality; May 2007. AHRQ Publication No. 07-0020.
Copy Citation
Save
S…
-
psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-errors-ambulatory-care-settings
November 10, 2021 - Government Resource
AHRQ announces interest in research on diagnostic errors in ambulatory care settings.
Citation Text:
AHRQ announces interest in research on diagnostic errors in ambulatory care settings. Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis N…
-
psnet.ahrq.gov/issue/former-pharmacist-indicted-manslaughter-after-med-error
October 17, 2018 - Newspaper/Magazine Article
Former pharmacist indicted for manslaughter after med error.
Citation Text:
Former pharmacist indicted for manslaughter after med error. Paul R. Drug Topics. September 17, 2007.
Copy Citation
Save
Save to your library
Print
…
-
psnet.ahrq.gov/issue/fda-advise-err-medication-errors-associated-cerebyx
May 02, 2018 - Newspaper/Magazine Article
FDA Advise-ERR: medication errors associated with Cerebyx.
Citation Text:
FDA Advise-ERR: medication errors associated with Cerebyx. ISMP Medication Safety Alert! Acute Care Edition. April 10, 2008;13:1-2.
Copy Citation
Save
Save to your…
-
psnet.ahrq.gov/issue/durasal-durezol-mix-illustrates-how-dangerous-product-problems-persist-long-after-recognition
June 10, 2018 - Newspaper/Magazine Article
Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.
Citation Text:
Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition. ISMP Medication Safety Alert! Acute care edition. …
-
psnet.ahrq.gov/node/42376/psn-pdf
December 18, 2013 - Changes to supervision in community pharmacy:
pharmacist and pharmacy support staff views. … Changes to supervision in community pharmacy: pharmacist
and pharmacy support staff views. … https://psnet.ahrq.gov/issue/changes-supervision-community-pharmacy-pharmacist-and-pharmacy-
support-staff-views … This focus group study sought to establish which daily activities within a community pharmacy required … https://psnet.ahrq.gov/issue/changes-supervision-community-pharmacy-pharmacist-and-pharmacy-support-staff-views