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psnet.ahrq.gov/issue/improving-usability-intravenous-medication-labels-support-safe-medication-delivery
September 26, 2016 - Study
Improving the usability of intravenous medication labels to support safe medication delivery.
Citation Text:
Bauer DT, Guerlain S. Improving the usability of intravenous medication labels to support safe medication delivery. International journal of industrial ergonomics. 2011;41…
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psnet.ahrq.gov/issue/current-status-monitoring-medication-practice
May 28, 2015 - Commentary
Current status of the monitoring of medication practice.
Citation Text:
Cousins D. Current status of the monitoring of medication practice. Am J Health Syst Pharm. 2009;66(5 Suppl 3):S49-56. doi:10.2146/ajhp080605.
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psnet.ahrq.gov/issue/safety-hospital-stroke-care
December 02, 2020 - Study
The safety of hospital stroke care.
Citation Text:
Holloway RG, Tuttle D, Baird T, et al. The safety of hospital stroke care. Neurology. 2007;68(8):550-555.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error-prevention-intravenous
December 22, 2021 - Special or Theme Issue
Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.
Citation Text:
Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation. Al…
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psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors
April 26, 2023 - Newspaper/Magazine Article
New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors.
Citation Text:
New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors. Lovelace Jr, B. NBC News. September 7, 2022.
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psnet.ahrq.gov/issue/caution-coloured-medication-and-colour-blind
April 24, 2018 - Image/Poster
Caution: coloured medication and the colour blind.
Citation Text:
Cole BL, Harris RW. Caution: coloured medication and the colour blind. Lancet. 2009;374(9691):720. doi:10.1016/S0140-6736(09)60313-5.
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psnet.ahrq.gov/node/39150/psn-pdf
June 10, 2018 - Shakespeare was on target—don't be a borrower or
lender.
June 10, 2018
https://psnet.ahrq.gov/issue/shakespeare-was-target-dont-be-borrower-or-lender
This piece describes the dangers of "borrowing" dispensed medications as a workaround in the presence of
pharmacy delays and shares strategies to eliminate the pract…
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psnet.ahrq.gov/node/40827/psn-pdf
October 05, 2011 - Educating for Safety.
October 5, 2011
Am J Pharm Edu. 2011;75(7):e140-e143.
https://psnet.ahrq.gov/issue/educating-safety
This special section discusses strategies for integrating safety concepts into pharmacy curricula to promote
safe medication practice.
https://psnet.ahrq.gov/issue/educating-safety
http…
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psnet.ahrq.gov/node/36257/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-7
This monthly selection of medication error reports provides examples of problems related to poorly
scanned pharmacy orders, ambiguous labeling, and abbreviation use.
https://psnet.ah…
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psnet.ahrq.gov/node/34021/psn-pdf
March 07, 2005 - Focusing on Medical Errors.
March 7, 2005
Temple WJ, ed. J Surg Oncol. 2004;88(3):111-199.
https://psnet.ahrq.gov/issue/focusing-medical-errors
This issue provides a review of medical error from a variety of perspectives, including pediatrics,
anesthesiology, pharmacy, pathology, laboratory medicine, and insurers.…
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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
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psnet.ahrq.gov/node/38703/psn-pdf
June 10, 2009 - Reduce medication errors through following metrics.
June 10, 2009
Drug Formulary Review. June 1, 2009.
https://psnet.ahrq.gov/issue/reduce-medication-errors-through-following-metrics
This news piece discusses how using measurement tools in the pharmacy setting could help reduce
medication errors.
https://psnet.a…
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psnet.ahrq.gov/node/37206/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR; Smetzer JL.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-17
This monthly selection of medication error reports discusses problems related to intravenous tubing
misconnections, unidentified medication patches, and after-hours pharm…
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psnet.ahrq.gov/node/38605/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-34
This monthly selection of reports discusses an error involving the routing of a printed label in the pharmacy,
describes examples of drug name confusion, and highlights an obscure dr…
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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/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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Dow…
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Duplicate Insulin Order
Citation Text:
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia
Citation Text:
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…