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psnet.ahrq.gov/node/60660/psn-pdf
July 09, 2020 - Pharmacist-led program to improve transitions from acute
care to skilled nursing facility care.
July 9, 2020
Achilleos M, McEwen J, Hoesly M, et al. Pharmacist-led program to improve transitions from acute care to
skilled nursing facility care. Am J Health Syst Pharm. 2020;77(12). doi:10.1093/ajhp/zxaa090.
https:/…
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psnet.ahrq.gov/node/72599/psn-pdf
December 23, 2020 - In the eye of the storm: the role of the pharmacist in
medication safety during the COVID-19 pandemic at an
urban teaching hospital.
December 23, 2020
Kanaan AO, Sullivan KM, Seed SM, et al. In the eye of the storm: the role of the pharmacist in medication
safety during the COVID-19 pandemic at an urban teaching h…
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psnet.ahrq.gov/node/865518/psn-pdf
April 10, 2024 - Decreasing prescribing errors in antimicrobial
stewardship program-restricted medications.
April 10, 2024
Tang KM, Lee P, Anosike BI, et al. Decreasing prescribing errors in antimicrobial stewardship program-
restricted medications. Hosp Pediatr. 2024;14(4):281-290. doi:10.1542/hpeds.2023-007548.
https://psnet.ahr…
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psnet.ahrq.gov/node/850932/psn-pdf
June 21, 2023 - Evaluation of detected medication errors within the
operating room at an academic medical center.
June 21, 2023
Wolf M, Rolf J, Nelson D, et al. Evaluation of detected medication errors within the operating room at an
academic medical center. Hosp Pharm. 2023;58(3):309-314. doi:10.1177/00185787221145110.
https://p…
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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…
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psnet.ahrq.gov/node/73656/psn-pdf
September 01, 2021 - Opioid prescribing to US children and young adults in
2019.
September 1, 2021
Chua K-P, Brummett CM, Conti RM, et al. Opioid prescribing to US children and young adults in 2019.
Pediatrics. 2021;148(3):e2021051539. doi:10.1542/peds.2021-051539.
https://psnet.ahrq.gov/issue/opioid-prescribing-us-children-and-young-…
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psnet.ahrq.gov/node/74060/psn-pdf
November 10, 2021 - Clinically significant medication errors in surgical units
detected by clinical pharmacist: a real-life study.
November 10, 2021
Renaudin P, Coste A, Audurier Y, et al. Clinically significant medication errors in surgical units detected by
clinical pharmacist: a real?life study. Basic Clin Pharmacol Toxicol. 2021;1…
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psnet.ahrq.gov/node/43644/psn-pdf
April 22, 2015 - SIMMEON-Prep study: SIMulation of Medication Errors in
ONcology: prevention of antineoplastic preparation
errors.
April 22, 2015
Sarfati L, Ranchon F, Vantard N, et al. SIMMEON-Prep study: SIMulation of Medication Errors in
ONcology: prevention of antineoplastic preparation errors. J Clin Pharm Ther. 2015;40(1):55…
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psnet.ahrq.gov/node/60052/psn-pdf
March 18, 2020 - Analysis of pharmacist-identified medication-related
problems at two United Kingdom hospitals: a prospective
observational study.
March 18, 2020
Geeson C, Wei L, Franklin BD. Analysis of pharmacist-identified medication-related problems at two United
Kingdom hospitals: a prospective observational study. Int J Phar…
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psnet.ahrq.gov/node/43808/psn-pdf
April 22, 2015 - Preventing iatrogenic overdose: a review of
in–emergency department opioid-related adverse drug
events and medication errors.
April 22, 2015
Beaudoin FL, Merchant RC, Janicki A, et al. Preventing iatrogenic overdose: a review of in-emergency
department opioid-related adverse drug events and medication errors. Ann …
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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/866852/psn-pdf
October 02, 2024 - Accuracy of a chatbot in answering questions that
patients should ask before taking a new medication.
October 2, 2024
Cornelison BR, Erstad BL, Edwards C. Accuracy of a chatbot in answering questions that patients should
ask before taking a new medication. J Am Pharm Assoc (2003). 2024;64(4):102110.
doi:10.1016/j.…
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psnet.ahrq.gov/node/45920/psn-pdf
May 05, 2017 - Examining the nature of interprofessional interventions
designed to promote patient safety: a narrative review.
May 5, 2017
Reeves ST, Clark E, Lawton S, et al. Examining the nature of interprofessional interventions designed to
promote patient safety: a narrative review. International Journal for Quality in Health…
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - Providers must also not hesitate to contact the dispensing pharmacies and use other tools such as online
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?
*
*
Source and Credits
This presentation is based on the May 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sidney W.A. Dekker, Ph…
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psnet.ahrq.gov/
March 25, 2025 - This website is up to date as of March 24, 2025. You will not be able to register for an account and will no longer be able to obtain Continuing Medical Education (CME), Maintenance of Certification (MOC), or Continuing Pharmacy Education (CPE) credits. We are not taking submissions for WebM&M cases, Innovations, Train…
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/49781/psn-pdf
January 01, 2017 - Hazards of Loading Doses
January 1, 2017
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-loading-doses
The Case
A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac
arrest. Two days after discharg…
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psnet.ahrq.gov/node/49634/psn-pdf
September 01, 2011 - Situational (Un)Awareness
September 1, 2011
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/situational-unawareness
The Case
A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver
function tests, including a bi…
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - owners, such as healthcare systems that collect real-world data from electronic
health records, claims, pharmacies