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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - individual clinicians can do to solve the overarching problem, it is vital that doctors, nurses, and pharmacists
-
psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - Oakbrook Terrace, IL: Joint Commission Resources and the American Society of Health-System Pharmacists
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - allergy specialists, penicillin allergy testing in hospital-based patients has been performed by nurses, pharmacists
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Nurses are a constant presence at the bedside and regularly interact with physicians, pharmacists, families
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - include members of the immediate care team (e.g., physicians, bedside nurses, case managers, therapists, pharmacists
-
psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - WebM&M Cases
Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - The primary nurse of the
patient is the one who presents but the pharmacist will have input, the case
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - adverse event
related to glucose management), by pharmacy during the order validation process (e.g., a pharmacist
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - WebM&M Cases
Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - November 15, 2023
In the eye of the storm: the role of the pharmacist in medication safety
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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - This reluctance is not specific to patientswhen the safety culture is poor, even doctors, nurses, pharmacists
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - near misses” in which incorrectly placed orders were caught, questioned, and corrected by nurses or pharmacists
-
psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - implement such a program is to create a team that includes key obstetricians, nurses,
anesthesiologists, pharmacists
-
psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - Many physicians, pharmacists, and nurses are unfamiliar with diabetes technology and therefore require
-
psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - In a simulation scenario with real people, in their real roles, such as doctors, nurses, and
pharmacists
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psnet.ahrq.gov/node/867357/psn-pdf
December 18, 2024 - The
team (nurses, physician, pharmacist, respiratory therapist) huddled before the procedure to ensure
-
psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - all the positive medication safety triggers in a hospital with about 600 beds with about 3 hours of pharmacists … events using a combination of "voluntary and verbally solicited reports from house officers, nurses, and pharmacists
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - events using a combination of "voluntary and verbally solicited reports from house officers, nurses, and pharmacists … all the positive medication safety triggers in a hospital with about 600 beds with about 3 hours of pharmacists
-
psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - population health expert, as well as healthcare providers, nurse educators, behavioral health
counselors, clinical … pharmacists, and care coordinators.
-
psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …