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psnet.ahrq.gov/node/35657/psn-pdf
July 05, 2013 - Pharmacist Staffing and the Use of Technology in Small
Rural Hospitals: Implications for Medication Safety.
July 5, 2013
Casey MM, Moscovice I, Davidson G. Minneapolis, MN: Upper Midwest Rural Health Research Center;
2005.
https://psnet.ahrq.gov/issue/pharmacist-staffing-and-use-technology-small-rural-hospitals-im…
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psnet.ahrq.gov/node/47345/psn-pdf
January 27, 2019 - Fixed-dose combination antihypertensives and risk of
medication errors.
January 27, 2019
Moriarty F, Bennett K, Fahey T. Fixed-dose combination antihypertensives and risk of medication errors.
Heart. 2019;105(3):204-209. doi:10.1136/heartjnl-2018-313492.
https://psnet.ahrq.gov/issue/fixed-dose-combination-antihype…
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psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - Medication Administration Errors
March 12, 2021
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/medication-administration-errors
Updated in March 2021. Originally published in January 2018 by researchers at the University of California,
San Fra…
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - Sick and Pregnant
Citation Text:
El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
January 01, 2004 - Most retail pharmacies do not mandate inclusion of the child’s
weight on written prescriptions. … Therefore, it is difficult for pharmacies to
correctly determine if a weight-based dosing error has
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digital.ahrq.gov/sites/default/files/docs/citation/r36hs021976-gatwood-final-report-2014.pdf
January 01, 2014 - Targeting Medication Nonadherence Using Mobile Phone-Based Tailored Messaging - FInal Report
Targeting Medication Nonadherence…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
March 01, 2002 - Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System
145
Reporting of Adverse Drug Events:
Examination of a Hospital Incident
Reporting System
Radhika Desikan, Melissa J. Krauss, W. Claiborne Dunagan,
Erin Christensen Rachmiel, Thomas Bailey, Victoria J. Fraser
Abstract
Ba…
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digital.ahrq.gov/ahrq-funded-projects/tulare-district-hospital-rural-health-electronic-medical-record-consortium-2
January 01, 2023 - Evaluating success. Strategies and challenges for understanding IT implementation in a rural hospital.
Citation
Spetz J, Keane D. Evaluating success. Strategies and challenges for understanding IT implementation in a rural hospital. J Healthc Inf Manag 2009 Winter;23(1):62-7.
Link
Spetz J, Ke…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/In-officePrescribing-PaperSystem.pdf
January 01, 2010 - Visio-Paper prescribing flowchart
In-office Prescribing – Paper system
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A
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in
is
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ta
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P
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at
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Patient sees
provider
Evaluate patient
Staff retrieves
patient’s chart and
brings to provider
Patient need
prescription
and/or refill?
Patient leaves …
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psnet.ahrq.gov/node/44990/psn-pdf
July 11, 2017 - Automatic errors: a case series on the errors inherent in
electronic prescribing.
July 11, 2017
Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic
Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5.
https://psnet.ahrq.gov/issue/automat…
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psnet.ahrq.gov/node/43875/psn-pdf
September 19, 2016 - Implementation of a "second victim" program in a
pediatric hospital.
September 19, 2016
Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital.
Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650.
https://psnet.ahrq.gov/issue/implementation-second-vic…
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psnet.ahrq.gov/node/41849/psn-pdf
December 05, 2012 - Improving care transitions: current practice and future
opportunities for pharmacists.
December 5, 2012
Pharmacy AC of C, Hume AL, Kirwin J, et al. Improving care transitions: current practice and future
opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi:10.1002/phar.1215.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/35583/psn-pdf
June 17, 2010 - Using a bar-coded medication administration system to
prevent medication errors in a community hospital
network.
June 17, 2010
Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent
medication errors in a community hospital network. American Journal of Health-System …
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psnet.ahrq.gov/node/853980/psn-pdf
September 27, 2023 - RFID tags reduce restocking errors of anesthesia
medications.
September 27, 2023
Banks MA. Specialty Pharmacy Continuum. September 15, 2023.
https://psnet.ahrq.gov/issue/rfid-tags-reduce-restocking-errors-anesthesia-medications
Radiofrequency identification (RFID) devices are being used to improve processes in the…
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psnet.ahrq.gov/node/842432/psn-pdf
January 11, 2023 - Medication errors: the year in review: January through
December 2021.
January 11, 2023
Pharmacy Practice News Special Edition. December 13, 2022: 43-54.
https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021
Medication errors continue to occur despite long-standing efforts to redu…
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psnet.ahrq.gov/node/863764/psn-pdf
March 06, 2024 - Medication errors 2023: the year in review: January
through December.
March 6, 2024
Pharmacy Practice News; February 2024: Suppl 1-12.
https://psnet.ahrq.gov/issue/medication-errors-2023-year-review-january-through-december
The medication process has multiple steps in it that can open the door to mistakes. This ar…
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www.ahrq.gov/sites/default/files/2024-01/basco-report.pdf
January 01, 2024 - Final Progress Report: Prescribing Errors in Ambulatory Pediatric Care
Title of Project: Prescribing Errors in Ambulatory Pediatric Care
Principal Investigator and Team Members:
Basco, William T. = PI
Simpson, Kit = Mentor
Hulsey, Thomas = Mentor, Director of Masters Degree Program
Ebeling, Myla = Co-investig…