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psnet.ahrq.gov/issue/supplemental-item-set-nursing-home-sops-call-pilot-participants
December 24, 2008 - June 28, 2023
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative
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psnet.ahrq.gov/issue/why-do-so-many-black-women-die-pregnancy-one-reason-doctors-dont-take-them-seriously
June 07, 2023 - 16, 2023
The nature, severity and causes of medication incidents from an Australian community … pharmacy incident reporting system: the QUMwatch study.
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psnet.ahrq.gov/issue/slowly-vanishing-prescription-pad
April 08, 2019 - See More About The Topic
Ambulatory Care
Physicians
Pharmacists
Medicine
Community … Pharmacy
View More
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psnet.ahrq.gov/issue/updates-hospital-survey-patient-safety-culture
October 23, 2019 - February 20, 2019
Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative
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psnet.ahrq.gov/node/842415/psn-pdf
January 11, 2023 - Accuracy of spinal anesthesia drug concentrations in
mixtures prepared by anesthetists.
January 11, 2023
Heesen M, Steuer C, Wiedemeier P, et al. Accuracy of spinal anesthesia drug concentrations in mixtures
prepared by anesthetists. J Patient Saf. 2022;18(8):e1226-e1230. doi:10.1097/pts.0000000000001061.
https://…
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psnet.ahrq.gov/node/36588/psn-pdf
March 03, 2011 - Oral chemotherapy safety practices at US cancer centres:
questionnaire survey.
March 3, 2011
Weingart SN, Flug J, Brouillard D, et al. Oral chemotherapy safety practices at US cancer centres:
questionnaire survey. BMJ. 2007;334(7590). doi:10.1136/bmj.39069.489757.55.
https://psnet.ahrq.gov/issue/oral-chemotherapy-…
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psnet.ahrq.gov/node/60762/psn-pdf
August 05, 2020 - Implementation and sustainability of a medication
reconciliation toolkit: a mixed methods evaluation.
August 5, 2020
Stolldorf DP, Mixon AS, Auerbach AD, et al. Implementation and sustainability of a medication
reconciliation toolkit: a mixed methods evaluation. Am J Health Syst Pharm. 2020;77(14):1135-1143.
doi:1…
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psnet.ahrq.gov/node/73688/psn-pdf
September 08, 2021 - Effect of medication reconciliation on patient reported
potential adverse events after hospital discharge.
September 8, 2021
Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Effect of medication reconciliation on patient reported
potential adverse events after hospital discharge. Res Social Adm Pharm. 2021;17(8):142…
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psnet.ahrq.gov/node/43828/psn-pdf
January 14, 2015 - Tragic error with neuromuscular blocker should prompt
risk assessment by all hospitals.
January 14, 2015
ISMP Medication Safety Alert! Acute Care Edition. December 18, 2014;19:1,4.
https://psnet.ahrq.gov/issue/tragic-error-neuromuscular-blocker-should-prompt-risk-assessment-all-
hospitals
This newsletter article …
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psnet.ahrq.gov/node/43631/psn-pdf
December 19, 2014 - An internal quality improvement collaborative
significantly reduces hospital-wide medication error
related adverse drug events.
December 19, 2014
McClead RE, Catt C, Davis T, et al. An internal quality improvement collaborative significantly reduces
hospital-wide medication error related adverse drug events. J Ped…
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psnet.ahrq.gov/node/866244/psn-pdf
July 10, 2024 - Optimizing the use of dose error reduction software on
intravenous infusion pumps.
July 10, 2024
Hughes K, Cole M, Tims D, et al. Optimizing the use of dose error reduction software on intravenous
infusion pumps. Hosp Pediatr. 2024;14(6):448-454. doi:10.1542/hpeds.2023-007385.
https://psnet.ahrq.gov/issue/optimizi…
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psnet.ahrq.gov/node/46575/psn-pdf
December 13, 2017 - Economic evaluation of pharmacist-led medication
reviews in residential aged care facilities.
December 13, 2017
Hasan SS, Thiruchelvam K, Kow CS, et al. Economic evaluation of pharmacist-led medication reviews in
residential aged care facilities. Expert Rev Pharmacoecon Outcomes Res. 2017;17(5):431-439.
doi:10.108…
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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/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/43353/psn-pdf
July 16, 2014 - Survey suggests possible downward trend in identifying
key drugs/drug classes as high-alert medications.
July 16, 2014
ISMP Medication Safety Alert! Acute care edition. July 3, 2014;19:1-3,5-6.
https://psnet.ahrq.gov/issue/survey-suggests-possible-downward-trend-identifying-key-drugsdrug-classes-
high-alert
This …
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psnet.ahrq.gov/node/853231/psn-pdf
September 06, 2023 - Development of a proactive process to harmonize policy,
infusion pump library, and electronic health record
entries for continuous infusions at an academic medical
center.
September 6, 2023
Christensen SM, Andrews SR, Fox ER. Development of a proactive process to harmonize policy, infusion
pump library, and elect…