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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type
1 Diabetes and Home Insulin Pump
October 28, 2020
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1
Diabetes and Home Insulin Pump . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - March 15, 2023
Medication reconciliation in a community pharmacy setting.
-
www.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
January 01, 2024 - Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care
AHRQ Final Report for grant R18HS024869
Title Leveraging a Social Network of Elders and Families to Improve
Medication Safety at Transitions of Care
Principal Investigator (PI) Yuri Quintana…
-
www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
January 01, 2024 - Final Progress Report: Improving Medication Safety Across Clinical Settings
FINAL REPORT: November 29, 2007
Improving Medication Safety Across Clinical Settings
Principal Investigator: David W. Bates; dbates@…
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psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
December 07, 2020 - A state’s PDMP contains information from dispensing pharmacies and tracks controlled substance prescriptions
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs016154-nashan-final-report-2009.pdf
January 01, 2009 - For example, the pharmacies working on e-
prescribing reported that the changes were currently more cumbersome
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/otimefallspx-implmatls.pdf
June 02, 2025 - Falls Prevention Self-Assessment Worksheet - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Agency for Healthcare Research and Quality Safety Program for Nursing Homes: On-Time Falls Prevention
AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention
Falls Prevention Self-Assessment Wo…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_7.pdf
October 01, 2016 - New Models of Primary Care Workforce and Financing - Case Example #7: Cherokee Health Systems
New Models of Primary Care
Workforce and Financing
Case
Example Cherokee Health Systems
7
New Models of Primary Care Workforce
and Financing
Case Example #7: Cherokee Health Systems
…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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digital.ahrq.gov/sites/default/files/docs/citation/k08hs24764-nanji-final-report-2022.pdf
January 01, 2022 - Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of Clinical Decision Support - Final Report
Preventing Perioperati…
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effectivehealthcare.ahrq.gov/sites/default/files/pulmonary-horizon-scan-high-impact-1306.pdf
June 01, 2013 - Ivacaftor costs between about $329,145 and $350,473 annually according to a June 2013 query
of online pharmacies
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-ASC-webcast-2023-0509-hare.pdf
January 01, 2023 - items)
• Background Questions (2 items)
17
SOPS Databases
Hospital Nursing
Home
Medical
Office
Community … Pharmacy
Ambulatory
Surgery
Center
18
SOPS ASC Database
• Repository of SOPS ASC
Survey Data
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-StJacques_105.pdf
March 29, 2008 - or group manages each
item (e.g., central supply, sterile instrument processing, patient transport, pharmacies
-
digital.ahrq.gov/sites/default/files/docs/citation/HealthITHazardManagerFinalReport.pdf
May 01, 2012 - prescriptions for post-discharge medications directly from its
electronic health record (EHR) to retail pharmacies … medications are frequently cancelled immediately prior to
the patient’s final discharge and few retail pharmacies … systems (e.g., the coordination of a patient’s post-
discharge medication list among hospital physicians, community … pharmacies, and outpatient
physicians).
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Feldstein.pdf
January 01, 2004 - Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study
35
Decision Support System Design and
Implementation for Outpatient Prescribing:
The Safety in Prescribing Study
Adrianne C. Feldstein, David H. Smith, Nan R. Robertson,
Christine A. Kovach, Stephen B…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
January 01, 2004 - “Near-miss” Reporting System Development and Implications for Human Subjects Protection
181
“Near-miss” Reporting System
Development and Implications
for Human Subjects Protection
Harvey J. Murff, Daniel W. Byrne, Paul A. Harris,
Daniel J. France, Christa Hedstrom, Robert S. Dittus
Abstract
Background: R…