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psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-leading-drug
June 10, 2018 - Newspaper/Magazine Article
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.
Citation Text:
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety…
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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. …
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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.
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psnet.ahrq.gov/issue/enhancing-your-medication-error-reporting-program-improve-global-medication-safety
June 10, 2018 - Webinar
Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety.
Citation Text:
Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety. Institute for Safe Medication Practices. September 15, 2020.
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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.
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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.
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psnet.ahrq.gov/issue/hospital-drug-errors-far-uncommon
February 11, 2015 - Newspaper/Magazine Article
Hospital drug errors far from uncommon.
Citation Text:
Hospital drug errors far from uncommon. Lin R-G II; Watanabe T.
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psnet.ahrq.gov/issue/review-fdas-approach-medical-product-shortages
June 22, 2011 - Book/Report
A Review of FDA’s Approach to Medical Product Shortages.
Citation Text:
A Review of FDA’s Approach to Medical Product Shortages. Silver Spring, MD: US Food and Drug Administration; October 31, 2011.
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psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
November 13, 2019 - Book/Report
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.
Citation Text:
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. Farnborough, UK; Healthcare…
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psnet.ahrq.gov/issue/how-safe-are-compounded-drugs
May 20, 2020 - Newspaper/Magazine Article
How safe are compounded drugs?
Citation Text:
How safe are compounded drugs? Beyzarov E. Drug Topics. September 18, 2006.
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psnet.ahrq.gov/issue/reduce-medication-errors-through-following-metrics
December 21, 2022 - Newspaper/Magazine Article
Reduce medication errors through following metrics.
Citation Text:
Reduce medication errors through following metrics. Drug Formulary Review. June 1, 2009.
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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.
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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.
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psnet.ahrq.gov/issue/ehealth-safety-impact-ict-patient-safety-and-risk-management
June 18, 2013 - Book/Report
eHealth for Safety: Impact of ICT on Patient Safety and Risk Management.
Citation Text:
eHealth for Safety: Impact of ICT on Patient Safety and Risk Management. European Commission Information Society and Media. October 2007
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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.
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psnet.ahrq.gov/issue/good-intention-uncertain-outcomeour-take-physician-dispensing-offices-and-clinics
February 13, 2019 - Newspaper/Magazine Article
Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.
Citation Text:
Good intention, uncertain outcome...our take on physician dispensing in offices and clinics. ISMP Medication Safety Alert! Acute care edition. March …
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - Sick and Pregnant
November 1, 2008
El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty
breathing. The patient informed the staff that she was 17 weeks pre…
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - Looking for Meds in All the Wrong Places
Citation Text:
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/classics
August 01, 2023 - Obstetrical Nursing
(6)
Palliative Care
(4)
Pharmacy
(48)
Community … Pharmacy
(5)
Hospital Pharmacy
(16)
Error Types … AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community … Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the