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psnet.ahrq.gov/primer/digital-health-literacy
August 30, 2023 - 2016
WebM&M Cases
Medication Errors in Retail Pharmacies
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psnet.ahrq.gov/issue/scaling-pharmacist-led-information-technology-intervention-pincer-reduce-hazardous
December 16, 2020 - Study
Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.
Citation Text:
Rodgers S, Taylor AC, Roberts SA, et al. Scaling-up a pharmacist-led information technology interven…
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psnet.ahrq.gov/issue/experience-hospital-initiated-medication-changes-older-people-multimorbidity-multicentre
August 18, 2021 - Study
Experience of hospital-initiated medication changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial.
Citation Text:
Thevelin S, Pétein C, Me…
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psnet.ahrq.gov/issue/comparing-safety-performance-and-user-perceptions-patient-specific-indication-based
December 18, 2019 - Study
Comparing safety, performance and user perceptions of a patient-specific indication-based prescribing tool with current practice: a mixed methods randomised user testing study.
Citation Text:
Feather C, Clarke J, Appelbaum N, et al. Comparing safety, performance and user perception…
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psnet.ahrq.gov/issue/indication-based-prescribing-prevents-wrong-patient-medication-errors-computerized-provider
September 01, 2016 - Study
Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).
Citation Text:
Galanter W, Falck S, Burns M, et al. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). …
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psnet.ahrq.gov/issue/hospital-staff-should-use-more-one-method-detect-adverse-events-and-potential-adverse-events
November 12, 2014 - Study
Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.
Citation Text:
Olsen S, Neale G, Schwab K, et al. Hospital staff should use mo…
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psnet.ahrq.gov/innovation/implementation-medication-reconciliation-risk-stratification-tool-integrated-within
April 12, 2023 - EMERGING INNOVATIONS
Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.
Citation Text:
Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratif…
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psnet.ahrq.gov/node/842432/psn-pdf
January 11, 2023 - Medication errors: the year in review: January through
December 2021.
January 11, 2023
Pharmacy Practice News Special Edition. December 13, 2022: 43-54.
https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021
Medication errors continue to occur despite long-standing efforts to redu…
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psnet.ahrq.gov/node/44990/psn-pdf
July 11, 2017 - Automatic errors: a case series on the errors inherent in
electronic prescribing.
July 11, 2017
Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic
Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5.
https://psnet.ahrq.gov/issue/automat…
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psnet.ahrq.gov/node/863764/psn-pdf
March 06, 2024 - Medication errors 2023: the year in review: January
through December.
March 6, 2024
Pharmacy Practice News; February 2024: Suppl 1-12.
https://psnet.ahrq.gov/issue/medication-errors-2023-year-review-january-through-december
The medication process has multiple steps in it that can open the door to mistakes. This ar…
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psnet.ahrq.gov/node/43875/psn-pdf
September 19, 2016 - Implementation of a "second victim" program in a
pediatric hospital.
September 19, 2016
Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital.
Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650.
https://psnet.ahrq.gov/issue/implementation-second-vic…
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psnet.ahrq.gov/node/41849/psn-pdf
December 05, 2012 - Improving care transitions: current practice and future
opportunities for pharmacists.
December 5, 2012
Pharmacy AC of C, Hume AL, Kirwin J, et al. Improving care transitions: current practice and future
opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi:10.1002/phar.1215.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/35583/psn-pdf
June 17, 2010 - Using a bar-coded medication administration system to
prevent medication errors in a community hospital
network.
June 17, 2010
Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent
medication errors in a community hospital network. American Journal of Health-System …
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psnet.ahrq.gov/node/853980/psn-pdf
September 27, 2023 - RFID tags reduce restocking errors of anesthesia
medications.
September 27, 2023
Banks MA. Specialty Pharmacy Continuum. September 15, 2023.
https://psnet.ahrq.gov/issue/rfid-tags-reduce-restocking-errors-anesthesia-medications
Radiofrequency identification (RFID) devices are being used to improve processes in the…
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - errors and minimize the time involved in completing clinical work.15
Prescriptions sent to retail pharmacies
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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psnet.ahrq.gov/node/72807/psn-pdf
March 03, 2021 - Updated guidance needed for longstanding large volume
parenteral (LVP) labeling and packaging problems.
March 3, 2021
ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4.
https://psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-
and-packaging
…
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psnet.ahrq.gov/node/47951/psn-pdf
April 24, 2019 - Safe medication management at ambulatory surgery
centers.
April 24, 2019
Ubaldi K. Safe Medication Management at Ambulatory Surgery Centers. AORN J. 2019;109(4):435-442.
doi:10.1002/aorn.12635.
https://psnet.ahrq.gov/issue/safe-medication-management-ambulatory-surgery-centers
Safe medication use can be challengin…
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psnet.ahrq.gov/node/42135/psn-pdf
April 22, 2013 - Interprofessional education in team communication:
working together to improve patient safety.
April 22, 2013
Brock DM, Abu-Rish E, Chiu C-R, et al. Interprofessional education in team communication: working
together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-23. doi:10.1136/bmjqs-2012-000952.
https:/…
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect adverse drug
events in the hospital setting.
March 10, 2011
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical
event monitor signals used to detect adverse …