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psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors
May 02, 2018 - Newspaper/Magazine Article
Misprogramming PCA concentration leads to dosing errors.
Citation Text:
Misprogramming PCA concentration leads to dosing errors. ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
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psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
September 09, 2015 - Newspaper/Magazine Article
Reminder: pay attention to the appearance of your medicines.
Citation Text:
Reminder: pay attention to the appearance of your medicines. ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
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psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
May 11, 2014 - Commentary
Implementing a bar-code medication administration system.
Citation Text:
Weber RJ. Implementing a Bar-Code Medication Administration System. Hosp Pharm. 2010;43(12):1016-1022. doi:10.1310/hpj4312-1016.
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psnet.ahrq.gov/issue/fluorouracil-error-ends-tragically-application-lessons-learned-will-save-lives
June 10, 2018 - Newspaper/Magazine Article
Fluorouracil error ends tragically, but application of lessons learned will save lives.
Citation Text:
Fluorouracil error ends tragically, but application of lessons learned will save lives. ISMP Medication Safety Alert! Acute care edition. September 20, 2007. …
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psnet.ahrq.gov/issue/errors-injectable-medications-unlabeled-syringes-are-surprisingly-common
December 27, 2018 - Newspaper/Magazine Article
Errors with injectable medications: unlabeled syringes are surprisingly common!
Citation Text:
Errors with injectable medications: unlabeled syringes are surprisingly common! ISMP Medication Safety Alert! Acute care edition. November 15, 2007.
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psnet.ahrq.gov/issue/technical-patient-safety-solutions-medicines-reconciliation-admission-adults-hospital
October 27, 2021 - Organizational Policy/Guidelines
Technical patient safety solutions for medicines reconciliation on admission of adults to hospital.
Citation Text:
Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. Manchester, UK: National Institute…
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psnet.ahrq.gov/issue/adc-survey-shows-some-improvements-unnecessary-risks-still-exist
January 23, 2019 - Newspaper/Magazine Article
ADC survey shows some improvements, but unnecessary risks still exist.
Citation Text:
ADC survey shows some improvements, but unnecessary risks still exist. ISMP Medication Safety Alert! Acute care edition. January 17, 2008.
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psnet.ahrq.gov/issue/proper-positioning-pharmacy-label-hospira-pca-vials-will-avoid-interference-scanning
May 05, 2018 - Newspaper/Magazine Article
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.
Citation Text:
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning. ISMP Medication Safety Alert! Acute Care Edition. Au…
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psnet.ahrq.gov/issue/insulin-pens-devices
August 31, 2016 - Special or Theme Issue
Insulin Pens Devices.
Citation Text:
Insulin Pens Devices. Am J Health Syst Pharm. 2016;73(19 suppl 5);s1-s47.
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psnet.ahrq.gov/training-education
October 01, 2025 - Training and Education Overview
PSNet offers an unparalleled set of resources for patient safety training and education. In this section, you will have the opportunity to read WebM&M (Morbidity & Mortality) Spotlight Cases and complete the interactive learning modules for continuing medical education (CME), maintenan…
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psnet.ahrq.gov/issue/cause-concern-drug-shortages-disrupt-operations-tax-hospitalists-treatment-patterns
March 27, 2005 - Newspaper/Magazine Article
Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns.
Citation Text:
Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns. Collins TR. The Hospitalist. July 2011.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
November 30, 2010 - medication use, and to reduce the risk of adverse events, including adverse drug interactions.”16
Pharmacies … Some commercial pharmacies already have an analogous system in place. … Comprehensive medication therapy management:
Identifying and resolving drug-related issues in a
community … pharmacy.
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psnet.ahrq.gov/issue/effect-health-information-exchange-recognition-medication-discrepancies-interrupted-when-data
November 16, 2022 - Study
Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.
Citation Text:
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…
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digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015236-jose-final-report-2008.pdf
January 01, 2008 - Comprehensive Information Technology Solution for Quality and Patient Safety - Final Report
§ †
Grant Final Report
Grant ID: UC1HS015236
Comprehensive Information Technology Solution f…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-5.html
March 01, 2022 - Improving Education—A Key to Better Diagnostic Outcomes
Next Steps and Barriers
Previous Page Next Page
Table of Contents
Improving Education—A Key to Better Diagnostic Outcomes
Introduction
Foundations of Diagnosis Education
Current State of Diagnosis Education
Competencies To Improve Diagn…
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digital.ahrq.gov/ahrq-funded-projects/comprehensive-information-technology-it-solution-quality-and-patient-safety
January 01, 2023 - Comprehensive Information Technology (IT) Solution for Quality and Patient Safety
Project Final Report ( PDF , 330.88 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily …
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digital.ahrq.gov/ahrq-funded-projects/tools-optimizing-medication-safety-top-meds/citation/cognitive-tests-predict
January 01, 2023 - Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.
Citation
Schroeder SR, Salomon MM, Galanter WL, et al. Cognitive tests predict real-world errors: the r…
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psnet.ahrq.gov/issue/impact-covid-19-pandemic-experiences-hospitalized-patients-scoping-review
September 21, 2022 - February 23, 2022
Mapping the resilience performance of community pharmacy to maintain
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psnet.ahrq.gov/issue/interplay-between-teamwork-clinicians-emotional-exhaustion-and-clinician-rated-patient-safety
April 01, 2015 - failure mode and effects analysis to reduce patient safety risks related to the dispensing process in the community … pharmacy setting.
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psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-and-its-associations-health-related-and-system-related
July 28, 2021 - Author(s)
The nature, severity and causes of medication incidents from an Australian community … pharmacy incident reporting system: the QUMwatch study.