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psnet.ahrq.gov/issue/survey-medication-documentation-hospital-discharge-implications-patient-safety-and-continuity
March 02, 2011 - Study
Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care.
Citation Text:
Grimes T, Delaney T, Duggan C, et al. Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care.…
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psnet.ahrq.gov/issue/patient-safety-education-change-medical-students-attitudes-and-sense-responsibility
January 20, 2021 - Study
Patient safety education to change medical students' attitudes and sense of responsibility.
Citation Text:
Roh H, Park SJ, Kim T. Patient safety education to change medical students' attitudes and sense of responsibility. Med Teach. 2015;37(10):908-14. doi:10.3109/0142159X.2014.970…
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psnet.ahrq.gov/issue/frequency-medication-errors-intravenous-acetylcysteine-acetaminophen-overdose
March 03, 2010 - Study
Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose.
Citation Text:
Hayes BD, Klein-Schwartz W, Doyon S. Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose. Ann Pharmacother. 2008;42(6):766-70. doi:10.13…
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psnet.ahrq.gov/issue/improving-quality-written-prescriptions-general-hospital-influence-10-years-serial-audits-and
August 24, 2022 - Study
Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions.
Citation Text:
Gommans J, McIntosh P, Bee S, et al. Improving the quality of written prescriptions in a general hospital: the influence of …
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psnet.ahrq.gov/node/41673/psn-pdf
September 12, 2012 - A root cause analysis project in a medication safety
course.
September 12, 2012
Schafer JJ. A root cause analysis project in a medication safety course. Am J Pharm Educ.
2012;76(6):116. doi:10.5688/ajpe766116.
https://psnet.ahrq.gov/issue/root-cause-analysis-project-medication-safety-course
This commentary descri…
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psnet.ahrq.gov/node/39519/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR, Smetzer JL. Neuromuscular Blocker Mix-up in the Pharmacy; ISMP and Doctor's Digest
Launch New iPhone Application; “UD” for “Ut Dictum”—an Ambiguous and Dangerous Abbreviation; Order
by Metric Weight, Not Volume. Hosp Pharm. 2010;45(4). doi:10.1310/hpj45…
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psnet.ahrq.gov/node/40830/psn-pdf
October 05, 2011 - "Tech-check-tech": a review of the evidence on its safety
and benefits.
October 5, 2011
Adams AJ, Martin SJ, Stolpe SF. "Tech-check-tech": a review of the evidence on its safety and benefits.
Am J Health Syst Pharm. 2011;68(19):1824-33. doi:10.2146/ajhp110022.
https://psnet.ahrq.gov/issue/tech-check-tech-review-ev…
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psnet.ahrq.gov/node/37819/psn-pdf
April 14, 2010 - Standardizing Medication Labels: Confusing Patients
Less, Workshop Summary.
April 14, 2010
Hernandez LM; for Roundtable on Health Literacy, Board on Population Health and Public Health Practice,
Institute of Medicine. Washington, DC: National Academies Press; 2008.
https://psnet.ahrq.gov/issue/standardizing-medica…
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psnet.ahrq.gov/node/40655/psn-pdf
September 12, 2016 - Impact of drug shortages on U.S. health systems.
September 12, 2016
Kaakeh R, Sweet B, Reilly C, et al. Impact of drug shortages on U.S. health systems. Am J Health Syst
Pharm. 2011;68(19):1811-9. doi:10.2146/ajhp110210.
https://psnet.ahrq.gov/issue/impact-drug-shortages-us-health-systems
This study surveyed pharm…
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psnet.ahrq.gov/node/50582/psn-pdf
October 23, 2019 - Medication errors: the year in review.
October 23, 2019
Valentine D, Ingram V, Fobi B et al. Pharmacy Practice News. September 10, 2019.
https://psnet.ahrq.gov/issue/medication-errors-year-review
Medication error prevention is an evolving goal for health care. This article discusses distinct medications
and errors…
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/42130/psn-pdf
June 10, 2018 - Survey results: community liaison programs to decrease
hospital readmissions.
June 10, 2018
ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.
https://psnet.ahrq.gov/issue/survey-results-community-liaison-programs-decrease-hospital-readmissions
This newsletter article details the characteristic…
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psnet.ahrq.gov/node/42807/psn-pdf
February 17, 2015 - ASPEN parenteral nutrition safety consensus
recommendations.
February 17, 2015
Ayers P, Adams S, Boullata JI, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations.
JPEN J Parenter Enteral Nutr. 2014;38(3):296-333. doi:10.1177/0148607113511992.
https://psnet.ahrq.gov/issue/aspen-parenteral-nutrit…
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psnet.ahrq.gov/node/49845/psn-pdf
October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug
Shortages
October 1, 2018
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
The Case
A 1-month-old preterm infant in the ne…
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psnet.ahrq.gov/node/50677/psn-pdf
November 20, 2019 - What Happens When Doctors Make Diagnostic Errors?
November 20, 2019
The Peoples Pharmacy. Show 1186: National Public Radio. October 24, 2019.
https://psnet.ahrq.gov/issue/what-happens-when-doctors-make-diagnostic-errors
Misdiagnosis growing area of concern in health care. This radio feature explores three commonly
…
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psnet.ahrq.gov/node/45063/psn-pdf
May 04, 2016 - Value of the pharmacist in the medication reconciliation
process.
May 4, 2016
Splawski J, Minger H. Value of the Pharmacist in the Medication Reconciliation Process. P T.
2016;41(3):176-8.
https://psnet.ahrq.gov/issue/value-pharmacist-medication-reconciliation-process
Medication reconciliation has been shown to r…
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psnet.ahrq.gov/node/43564/psn-pdf
January 15, 2019 - Are hospitals in a med safety standard slump?
January 15, 2019
Wild D. Pharmacy Practice News. September 8, 2014.
https://psnet.ahrq.gov/issue/are-hospitals-med-safety-standard-slump
Highlighting how hospital compliance rates with Joint Commission medication–related standards have
remained mostly unchanged from 20…
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psnet.ahrq.gov/issue/effect-health-care-working-conditions-patient-safety-evidence-reporttechnology-assessment
December 18, 2008 - March 18, 2020
Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative
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psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-long-term-care
December 24, 2008 - June 28, 2023
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative