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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Most importantly, a lack of efficient two-way communication between physician offices and pharmacies
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psnet.ahrq.gov/node/37161/psn-pdf
January 20, 2010 - Attitudes of health sciences faculty members towards
interprofessional teamwork and education.
January 20, 2010
Curran VR, Sharpe D, Forristall J. Attitudes of health sciences faculty members towards interprofessional
teamwork and education. Med Educ. 2007;41(9):892-896.
https://psnet.ahrq.gov/issue/attitudes-heal…
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psnet.ahrq.gov/node/60061/psn-pdf
March 18, 2020 - The glaring loophole in U.S. virus response: human error.
March 18, 2020
Ehley B. Politico. March 2, 2020.
https://psnet.ahrq.gov/issue/glaring-loophole-us-virus-response-human-error
This news story illustrates the potential for failure - attributable to human error, inexperience or external
stressors - in respons…
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psnet.ahrq.gov/node/35211/psn-pdf
June 13, 2011 - JCAHO views medication reconciliation as adverse-event
prevention.
June 13, 2011
Thompson CA. JCAHO views medication reconciliation as adverse-event prevention. American journal of
health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.
2005;62(15):1528, 1530, 1532.
…
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - February 26, 2014
Communicating medication changes to community pharmacy post-discharge
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psnet.ahrq.gov/innovations
February 26, 2025 - Obstetrical Nursing
(1)
Palliative Care
(1)
Pharmacy
(3)
Community … Pharmacy
(1)
Hospital Pharmacy
(2)
Error Types
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psnet.ahrq.gov/node/47588/psn-pdf
November 21, 2018 - 2 MSO programs show value of safety position.
November 21, 2018
Wild D. Pharmacy Practice News. November 8, 2018.
https://psnet.ahrq.gov/issue/2-mso-programs-show-value-safety-position
Medication safety officers serve as organizational champions of medication management process
improvement. This news article offer…
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psnet.ahrq.gov/node/41380/psn-pdf
June 20, 2012 - A novel tool for organisational learning and its impact on
safety culture in a hospital dispensary.
June 20, 2012
Sujan MA. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.
Reliab Eng Syst Saf. 2012;101:21-34. doi:10.1016/j.ress.2011.12.021.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/43327/psn-pdf
July 09, 2014 - Interprofessional learning for medication safety.
July 9, 2014
Hardisty J, Scott L, Chandler S, et al. Interprofessional learning for medication safety. Clin Teach.
2014;11(4):290-6. doi:10.1111/tct.12148.
https://psnet.ahrq.gov/issue/interprofessional-learning-medication-safety
This commentary describes the devel…
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psnet.ahrq.gov/node/40771/psn-pdf
June 15, 2012 - Medication prescribing errors in the prehospital setting
and in the ED.
June 15, 2012
Lifshitz AE, Goldstein LH, Sharist M, et al. Medication prescribing errors in the prehospital setting and in
the ED. Am J Emerg Med. 2012;30(5):726-31. doi:10.1016/j.ajem.2011.04.023.
https://psnet.ahrq.gov/issue/medication-presc…
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psnet.ahrq.gov/node/35271/psn-pdf
June 29, 2009 - Use of specific indicators to detect warfarin-related
adverse events.
June 29, 2009
Hartis CE, Gum MO, Lederer JW. Use of specific indicators to detect warfarin-related adverse events.
American Journal of Health-System Pharmacy. 2005;62(16). doi:10.2146/ajhp040404.
https://psnet.ahrq.gov/issue/use-specific-indic…
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psnet.ahrq.gov/node/36360/psn-pdf
October 28, 2010 - Pharmacist staffing, technology use, and implementation
of medication safety practices in rural hospitals.
October 28, 2010
Casey M, Moscovice I, Davidson G. Pharmacist staffing, technology use, and implementation of medication
safety practices in rural hospitals. J Rural Health. 2006;22(4):321-30.
https://psnet.a…
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psnet.ahrq.gov/node/73872/psn-pdf
September 22, 2021 - Parenteral nutrition safety.
September 22, 2021
Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.
https://psnet.ahrq.gov/issue/parenteral-nutrition-safety
Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm.
This article discusses …
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psnet.ahrq.gov/node/40733/psn-pdf
August 31, 2011 - Beyond the prescription: medication monitoring and
adverse drug events in older adults.
August 31, 2011
Steinman MA, Handler S, Gurwitz JH, et al. Beyond the prescription: medication monitoring and adverse
drug events in older adults. J Am Geriatr Soc. 2011;59(8):1513-1520. doi:10.1111/j.1532-
5415.2011.03500.x.
…
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psnet.ahrq.gov/node/36499/psn-pdf
January 07, 2011 - Retrospective analysis of medication incidents reported
using an on-line reporting system.
January 7, 2011
Ashcroft DM, Cooke J. Retrospective analysis of medication incidents reported using an on-line reporting
system. Pharmacy World & Science. 2006;28(6). doi:10.1007/s11096-006-9040-8.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/853626/psn-pdf
September 20, 2023 - Uncovering the shocking dangers of misdiagnosis.
September 20, 2023
Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.
https://psnet.ahrq.gov/issue/uncovering-shocking-dangers-misdiagnosis
Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker
discusses foun…
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psnet.ahrq.gov/node/49652/psn-pdf
May 01, 2012 - Double Dose at Transfer
May 1, 2012
Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/double-dose-transfer
The Case
A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department
(ED) for left lower extremity pain, swelling, and erythe…
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psnet.ahrq.gov/node/45334/psn-pdf
September 07, 2016 - Why 'Universal Precautions' are needed for medication
lists.
September 7, 2016
Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. 2016;25(9):731-2.
doi:10.1136/bmjqs-2015-005116.
https://psnet.ahrq.gov/issue/why-universal-precautions-are-needed-medication-lists
Despite the support…
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psnet.ahrq.gov/node/39161/psn-pdf
December 09, 2009 - Medication reconciliation at an academic medical center:
implementation of a comprehensive program from
admission to discharge.
December 9, 2009
Murphy EM, Oxencis CJ, Klauck JA, et al. Medication reconciliation at an academic medical center:
implementation of a comprehensive program from admission to discharge. A…
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psnet.ahrq.gov/node/40091/psn-pdf
December 15, 2010 - Implementation of a telepharmacy service to provide
round-the-clock medication order review by pharmacists.
December 15, 2010
Wakefield DS, Ward MM, Loes JL, et al. Implementation of a telepharmacy service to provide round-the-
clock medication order review by pharmacists. American Journal of Health-System Pharmacy…