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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
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Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength
Citation Text:
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - When the Indications for Drug Administration Blur
June 24, 2020
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre…
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psnet.ahrq.gov/node/61079/psn-pdf
October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication
Error in an Uncommon Indication
October 28, 2020
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-
…
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psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
June 01, 2014 - We could make sure that supplies are available at or near the bedside to decentralize pharmacies, so
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - Commission issued its 1998 Sentinel Alert about keeping concentrated potassium chloride only in hospital pharmacies … ( 11 ) found that delays in receiving dilute solutions from the pharmacy turned ICUs into de facto pharmacies
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - patients with information about the newly prescribed medication and/or offering counseling at local pharmacies
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/issue/fentanyl-patch-can-be-deadly-children
January 13, 2021 - Fact Sheet/FAQs
Accidental exposures to fentanyl patches continue to be deadly to children.
Citation Text:
Accidental exposures to fentanyl patches continue to be deadly to children. Rockville, MD: US Food and Drug Administration; 2021.
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psnet.ahrq.gov/issue/heparin-errors-continue-despite-prior-high-profile-fatal-events
May 02, 2018 - Newspaper/Magazine Article
Heparin errors continue despite prior, high-profile, fatal events.
Citation Text:
Heparin errors continue despite prior, high-profile, fatal events. ISMP Medication Safety Alert! Acute Care Edition. July 17, 2008;13:1-2.
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…
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psnet.ahrq.gov/issue/benefits-and-risks-including-patients-rca-teams
May 02, 2018 - Newspaper/Magazine Article
Benefits and risks of including patients on RCA teams.
Citation Text:
Benefits and risks of including patients on RCA teams. ISMP Medication Safety Alert! Acute Care Edition. June 5, 2008;13:1-3.
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - Fact Sheet/FAQs
10 Medication Safety Tips for Hospitalized Patients.
Citation Text:
10 Medication Safety Tips for Hospitalized Patients. Horsham, PA: Institute for Safe Medication Practices; 2019.
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psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
September 02, 2014 - Book/Report
Fluorouracil Incident Root Cause Analysis Report.
Citation Text:
Fluorouracil Incident Root Cause Analysis Report. Toronto, CA: Institute for Safe Medication Practices Canada; May 2007.
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psnet.ahrq.gov/issue/barcode-technology-flaws-put-some-patients-risk
July 23, 2008 - Newspaper/Magazine Article
Barcode technology flaws put some patients at risk.
Citation Text:
Barcode technology flaws put some patients at risk. Preidt R. ABC News. July 4, 2008.
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psnet.ahrq.gov/issue/consumer-guide-adverse-health-events
June 04, 2024 - Book/Report
Consumer Guide to Adverse Health Events.
Citation Text:
Consumer Guide to Adverse Health Events. St Paul, MN: Minnesota Department of Health; 2015.
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psnet.ahrq.gov/issue/protect-patients-against-preventable-harm-improper-use-single-dosesingle-use-vials
June 11, 2014 - Government Resource
Protect Patients Against Preventable Harm from Improper Use of Single-dose⁄Single-use Vials.
Citation Text:
Protect Patients Against Preventable Harm from Improper Use of Single-dose⁄Single-use Vials. Atlanta, GA: Centers for Disease Control and Prevention; May 2,…
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psnet.ahrq.gov/issue/ashp-statement-bar-code-verification-during-inventory-preparation-and-dispensing-medications
June 17, 2014 - Organizational Policy/Guidelines
ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications.
Citation Text:
ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications. Am J Health-Syst Pharm. 2011;68:44…
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psnet.ahrq.gov/issue/medical-errors-still-claiming-many-lives
September 19, 2007 - Newspaper/Magazine Article
Medical errors still claiming many lives.
Citation Text:
Medical errors still claiming many lives. Weise E. USA Today. May 18, 2005.
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psnet.ahrq.gov/issue/curing-our-diagnostic-disorder
December 04, 2019 - Newspaper/Magazine Article
Curing our diagnostic disorder.
Citation Text:
Curing our diagnostic disorder. Laposata M. The Pathologist. September 2017;(34):18-27.
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