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psnet.ahrq.gov/issue/opioid-overdose
April 06, 2022 - Government Resource
Opioid Overdose.
Citation Text:
Opioid Overdose. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/how-american-health-care-killed-my-father
February 13, 2013 - Newspaper/Magazine Article
How American health care killed my father.
Citation Text:
How American health care killed my father. Goldhill D. The Atlantic. September 2009.
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psnet.ahrq.gov/issue/can-we-ensure-medication-safety-use-speech-recognition-software
July 10, 2024 - Newspaper/Magazine Article
Can we ensure medication safety with the use of speech recognition software?
Citation Text:
Can we ensure medication safety with the use of speech recognition software? ISMP Medication Safety Alert! Acute Care. August 22, 2024;29(17):1-3.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-40
January 17, 2018 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR; Smetzer JL.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-27
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR. Hosp Pharm. 2008;43:547-550, 554.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-18
December 30, 2014 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR; Smetzer JL. Hosp Pharm. 2007;42(10):884-887.
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psnet.ahrq.gov/issue/2024-network-patient-safety-databases-chartbook-medication-and-other-substance-events
September 11, 2024 - Book/Report
2024 Network of Patient Safety Databases Chartbook: Medication and Other Substance Events.
Citation Text:
2024 Network Of Patient Safety Databases Chartbook: Medication And Other Substance Events. Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Pub. No. …
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psnet.ahrq.gov/primer/medication-reconciliation
March 15, 2025 - Medication Reconciliation
Citation Text:
Medication Reconciliation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction
Citation Text:
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - Psychiatric Nursing
(2)
Palliative Care
(12)
Pharmacy
(53)
Community … Pharmacy
(13)
Hospital Pharmacy
(25)
Error Types
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - An Inadvertent Bolus of Norepinephrine.
May 26, 2021
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - factors associated with safety climate, patient satisfaction and self-reported medicines adherence in community … pharmacies.
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psnet.ahrq.gov/issue/ismp-medication-safety-self-assessment-hospitals
April 17, 2024 - Measurement Tool/Indicator
ISMP Medication Safety Self Assessment for Hospitals.
Citation Text:
ISMP Medication Safety Self Assessment for Hospitals. Horsham, PA: Institute for Safe Medication Practices; April 2011.
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psnet.ahrq.gov/issue/considering-insulin-pens-routine-hospital-use-consider
May 03, 2023 - Newspaper/Magazine Article
Considering insulin pens for routine hospital use? Consider this...
Citation Text:
Considering insulin pens for routine hospital use? Consider this... ISMP Medication Safety Alert! Acute Care Edition. May 8, 2008;13:1-3.
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psnet.ahrq.gov/issue/quick-tips-when-getting-prescription
December 24, 2008 - Government Resource
Quick Tips—When Getting A Prescription.
Citation Text:
Quick Tips—When Getting A Prescription. Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/issue/drug-labeling-and-packaging-looking-beyond-what-meets-eye
April 16, 2018 - Newspaper/Magazine Article
Drug labeling and packaging — looking beyond what meets the eye.
Citation Text:
Drug labeling and packaging — looking beyond what meets the eye. PA-PSRS Patient Safety Advisory.
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