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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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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/45200/psn-pdf
May 09, 2017 - Safe implementation of standard concentration infusions
in paediatric intensive care.
May 9, 2017
Arenas-López S, Stanley IM, Tunstell P, et al. Safe implementation of standard concentration infusions in
paediatric intensive care. Journal of Pharmacy and Pharmacology. 2016;69(5). doi:10.1111/jphp.12580.
https://ps…
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psnet.ahrq.gov/node/34657/psn-pdf
June 14, 2011 - Multidisciplinary approaches to reducing error and risk in
a patient care setting.
June 14, 2011
Connor M, Ponte PR, Conway JB. Multidisciplinary approaches to reducing error and risk in a patient care
setting. Crit Care Nurs Clin North Am. 2002;14(4):359-67, viii.
https://psnet.ahrq.gov/issue/multidisciplinary-ap…
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psnet.ahrq.gov/node/60196/psn-pdf
April 01, 2020 - Mask shortage straps pharmacists who need them to
keep medicines pure.
April 1, 2020
Jewett C, Lupkin S. Health Shots. National Public Radio. March 20, 2020.
https://psnet.ahrq.gov/issue/mask-shortage-straps-pharmacists-who-need-them-keep-medicines-pure
Disruptions in medication compounding activities can impact s…
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psnet.ahrq.gov/node/38448/psn-pdf
March 04, 2009 - Medication errors: the impact of prescribing and
transcribing errors on preventable harm in hospitalised
patients.
March 4, 2009
van Doormaal JE, van den Bemt PMLA, Mol PGM, et al. Medication errors: the impact of prescribing and
transcribing errors on preventable harm in hospitalised patients. Qual Saf Health Car…
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psnet.ahrq.gov/node/74697/psn-pdf
January 26, 2022 - The effect of medication reconciliation via a patient portal
on medication discrepancies: a randomized noninferiority
study.
January 26, 2022
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. The effect of medication reconciliation via a
patient portal on medication discrepancies: a randomized noninferiority stu…
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psnet.ahrq.gov/node/836721/psn-pdf
March 09, 2022 - Sources of medication omissions among hospitalized
older adults with polypharmacy.
March 9, 2022
Shah AS, Hollingsworth EK, Shotwell MS, et al. Sources of medication omissions among hospitalized older
adults with polypharmacy. J Am Geriatr Soc. 2022;70(4):1180-1189. doi:10.1111/jgs.17629.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47964/psn-pdf
May 15, 2019 - Deaths among opioid users: impact of potential
inappropriate prescribing practices.
May 15, 2019
Jayawardhana J, Abraham AJ, Perri M. Deaths among opioid users: impact of potential inappropriate
prescribing practices. Am J Manag Care. 2019;25(4):e98-e103.
https://psnet.ahrq.gov/issue/deaths-among-opioid-users-impa…
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psnet.ahrq.gov/node/36559/psn-pdf
July 14, 2010 - Description and evaluation of an interprofessional patient
safety course for health professions and related sciences
students.
July 14, 2010
Galt KA, Paschal KA, O'Brien RL, et al. Description and Evaluation of an Interprofessional Patient Safety
Course for Health Professions and Related Sciences Students. J Patie…
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psnet.ahrq.gov/node/73069/psn-pdf
March 24, 2021 - Evaluation of the quality of 'do not use' medication
abbreviation audits: a key enabler to successful
implementation of audit and feedback.
March 24, 2021
Li E, Marrandino J, Marshall S, et al. Evaluation of the quality of ‘do not use’ medication abbreviation
audits: a key enabler to successful implementation of a…
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psnet.ahrq.gov/node/35928/psn-pdf
June 09, 2011 - Clinical pharmacists and inpatient medical care: a
systematic review.
June 9, 2011
Kaboli PJ, Hoth AB, McClimon BJ, et al. Clinical pharmacists and inpatient medical care: a systematic
review. Arch Intern Med. 2006;166(9):955-64.
https://psnet.ahrq.gov/issue/clinical-pharmacists-and-inpatient-medical-care-systemat…
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psnet.ahrq.gov/node/74856/psn-pdf
February 23, 2022 - The secondary use of data to support medication safety
in the hospital setting: a systematic review and narrative
synthesis.
February 23, 2022
Chaudhry NT, Franklin BD, Mohammed S, et al. The secondary use of data to support medication safety in
the hospital setting: a systematic review and narrative synthesis. Ph…
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psnet.ahrq.gov/node/45464/psn-pdf
September 07, 2016 - Measuring adverse events in hospitalized patients: an
administrative method for measuring harm.
September 7, 2016
Martin J, Benjamin EM, Craver C, et al. Measuring Adverse Events in Hospitalized Patients: An
Administrative Method for Measuring Harm. J Patient Saf. 2016;12(3):125-31.
doi:10.1097/PTS.000000000000007…
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psnet.ahrq.gov/node/44771/psn-pdf
January 06, 2016 - Could it be done safely? Pharmacists views on safety and
clinical outcomes from the introduction of an advanced
role for technicians.
January 6, 2016
Napier P, Norris P, Braund R. Could it be done safely? Pharmacists views on safety and clinical outcomes
from the introduction of an advanced role for technicians. R…
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psnet.ahrq.gov/node/73524/psn-pdf
July 21, 2021 - Intravenous admixture preparation considerations, Parts
9-A and 9-B: error prevention in intravenous admixture
preparation.
July 21, 2021
Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.
https://psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error-
prevention-…
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psnet.ahrq.gov/node/46264/psn-pdf
August 09, 2017 - Intraoperative handoffs among anesthesia providers
increase the incidence of documentation errors for
controlled drugs.
August 9, 2017
Epstein RH, Dexter F, Gratch DM, et al. Intraoperative Handoffs Among Anesthesia Providers Increase the
Incidence of Documentation Errors for Controlled Drugs. Jt Comm J Qual Patie…
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psnet.ahrq.gov/node/46530/psn-pdf
February 03, 2018 - Identifying and characterizing preventable adverse drug
events for prioritizing pharmacist intervention in
hospitals.
February 3, 2018
Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for
prioritizing pharmacist intervention in hospitals. Am J Health Syst Pharm. 2017…
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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…