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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - By standardizing concentrations of high alert medications, hospital pharmacies can provide ready-to-use
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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/node/72564/psn-pdf
November 14, 2018 - A state’s PDMP contains information from dispensing pharmacies and tracks controlled
substance prescriptions
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Specific downtime procedures could include calling pharmacies
to retrieve medication information, using
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Of these, 41% of the errors reported from community pharmacies involved choosing the wrong medication
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psnet.ahrq.gov/issue/medication-errors
August 21, 2018 - Commentary
Medication errors.
Citation Text:
Medication errors. Hartigan-Go K. Int J Risk Safety Med. 2006;18(3):181-186.
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psnet.ahrq.gov/issue/computer-technology-and-clinical-work-still-waiting-godot
October 19, 2022 - Commentary
Computer technology and clinical work: still waiting for Godot.
Citation Text:
Wears RL, Berg M. Computer Technology and Clinical Work. JAMA. 2005;293(10). doi:10.1001/jama.293.10.1261.
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psnet.ahrq.gov/issue/advancing-anticoagulation-stewardship-playbook
March 23, 2012 - Book/Report
Advancing Anticoagulation Stewardship: A Playbook.
Citation Text:
Advancing Anticoagulation Stewardship: A Playbook. Washington DC; National Quality Forum and Anticoagulation Forum; 2022.
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psnet.ahrq.gov/issue/ismps-list-high-alert-medications-acute-care-settings
April 17, 2024 - Fact Sheet/FAQs
ISMP's List of High-Alert Medications in Acute Care Settings.
Citation Text:
ISMP's List of High-Alert Medications in Acute Care Settings. Horsham, PA; Institute for Safe Medication Practices: 2024.
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Pri…
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psnet.ahrq.gov/issue/potassium-may-no-longer-be-stocked-patient-care-units-serious-threats-still-exist
May 02, 2018 - Newspaper/Magazine Article
Potassium may no longer be stocked on patient care units, but serious threats still exist!
Citation Text:
Potassium may no longer be stocked on patient care units, but serious threats still exist! ISMP Medication Safety Alert! Acute care edition. October 4, 200…
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psnet.ahrq.gov/issue/communicating-clearly-about-medicines-proceedings-workshop
September 12, 2018 - Meeting/Conference Proceedings
Communicating Clearly About Medicines: Proceedings of a Workshop.
Citation Text:
Communicating Clearly About Medicines: Proceedings of a Workshop. National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017.…
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psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors-may-slip-through
June 24, 2020 - Newspaper/Magazine Article
Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks.
Citation Text:
Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks. O'Donnell J. USA Today. September 8, 2020
…
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psnet.ahrq.gov/issue/polypharmacy-0
October 09, 2013 - Special or Theme Issue
Polypharmacy.
Citation Text:
Polypharmacy. Schneider E, Koretz BK, eds. Clin Geriatr Med. 2022;38(4):621-732.
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psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error
June 10, 2018 - Newspaper/Magazine Article
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.
Citation Text:
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1…
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psnet.ahrq.gov/issue/global-burden-preventable-medication-related-harm-health-care-systematic-review
November 15, 2023 - Book/Report
Global Burden of Preventable Medication-related Harm in Health Care: A Systematic Review.
Citation Text:
Global Burden of Preventable Medication-related Harm in Health Care: A Systematic Review. Geneva, Switzerland: World Health Organization; 2023. ISBN: 9789240088887.
Co…
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psnet.ahrq.gov/issue/prevention-adverse-drug-events-hospitals
July 23, 2014 - Review
Prevention of adverse drug events in hospitals.
Citation Text:
Prevention of adverse drug events in hospitals. Zhu J, Weingart SN. UpToDate. February 29, 2024.
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psnet.ahrq.gov/issue/eliminating-serious-preventable-and-costly-medical-errors-never-events
May 26, 2021 - Press Release/Announcement
Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.
Citation Text:
Eliminating Serious, Preventable, and Costly Medical Errors - Never Events. Baltimore, MD: Centers for Medicare and Medicaid Services; May 18, 2006.
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psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice
October 11, 2016 - Commentary
Understanding models of error and how they apply in clinical practice.
Citation Text:
Understanding models of error and how they apply in clinical practice. Garfield S, Franklin BD. Pharm J. June 14, 2016.
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psnet.ahrq.gov/issue/improving-heparin-safety-multidisciplinary-invited-conference
July 10, 2019 - Meeting/Conference Proceedings
Improving heparin safety: a multidisciplinary invited conference.
Citation Text:
Peterson C, Ham CW, Vanderveen T. Improving Heparin Safety: A Multidisciplinary Invited Conference. doi:10.1310/hpj4306-491.
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DOI Google Scho…