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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - involvement of pharmacists in direct drug therapy management, and, at present, the fastest growing clinical pharmacy … Alldredge, PharmD Professor of Clinical Pharmacy & Neurology Associate Dean, Academic Affairs, School … of Pharmacy University of California, San Francisco Faculty Disclosure: Dr.
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - drugs have more than one doctor who prescribes
the medicines, and about one-third use more than one pharmacy … coach to inventory these
items is more effective than relying on a list of prescriptions provided by a pharmacy … consultation, or per
hour), while others build relationships with academic pharmacists who supervise pharmacy
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psnet.ahrq.gov/issue/drug-calculation-ability-qualified-paramedics-pilot-study
June 25, 2018 - Study
Drug calculation ability of qualified paramedics: a pilot study.
Citation Text:
Boyle MJ, Eastwood K. Drug calculation ability of qualified paramedics: A pilot study. World J Emerg Med. 2018;9(1):41-45. doi:10.5847/wjem.j.1920-8642.2018.01.006.
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Format:
D…
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psnet.ahrq.gov/issue/stakeholder-safety-communication-patient-and-family-reports-safety-risks-hospitals
July 28, 2021 - Study
Stakeholder safety communication: patient and family reports on safety risks in hospitals.
Citation Text:
Reader TW. Stakeholder safety communication: patient and family reports on safety risks in hospitals. J Risk Res. 2022;25(7):807-824. doi:10.1080/13669877.2022.2061036.
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psnet.ahrq.gov/issue/failure-rescue-female-patients-undergoing-high-risk-surgery
October 25, 2017 - Study
Failure to rescue female patients undergoing high-risk surgery.
Citation Text:
Wagner CM, Joynt Maddox KE, Ailawadi G, et al. Failure to rescue female patients undergoing high-risk surgery. JAMA Surg. 2024;160(1):29-36. doi:10.1001/jamasurg.2024.4574.
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psnet.ahrq.gov/issue/engaging-patients-vigilant-partners-safety-systematic-review
February 06, 2019 - Review
Classic
Engaging patients as vigilant partners in safety: a systematic review.
Citation Text:
Schwappach DLB. Engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-148. doi:10.1177/1077558709342254.
Co…
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psnet.ahrq.gov/issue/ergonomic-and-human-factors-affecting-anesthetic-vigilance-and-monitoring-performance
May 31, 2011 - Review
Classic
Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment.
Citation Text:
Biebuyck J F, Weinger M B, Englund C E. Ergonomic and Human Factors Affecting Anesthetic Vigilance and Monitori…
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psnet.ahrq.gov/issue/what-causes-medication-administration-errors-mental-health-hospital-qualitative-study-nursing
March 11, 2020 - Study
What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.
Citation Text:
Keers RN, Plácido M, Bennett K, et al. What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. …
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psnet.ahrq.gov/issue/hospital-and-system-wide-interventions-health-care-associated-infections-systematic-review
January 12, 2022 - Review
Hospital- and system-wide interventions for health care-associated infections: a systematic review.
Citation Text:
Maurer NR, Hogan TH, Walker DM. Hospital- and system-wide interventions for health care-associated infections: a systematic review. Med Care Res Rev. 2021;78(6):643-6…
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psnet.ahrq.gov/issue/multiple-component-patient-safety-intervention-english-hospitals-controlled-evaluation-second
February 23, 2011 - Study
Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.
Citation Text:
Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 20…
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psnet.ahrq.gov/issue/patterns-potential-opioid-misuse-and-subsequent-adverse-outcomes-medicare-2008-2012
June 30, 2021 - Study
Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012.
Citation Text:
Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7…
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psnet.ahrq.gov/issue/human-factors-intervention-hospital-evaluating-outcome-teamstepps-program-surgical-ward
November 03, 2021 - Study
A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward.
Citation Text:
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. A human factors intervention in a hospital - evaluating the outcome of a TeamSTEPPS program in a surgical ward. …
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psnet.ahrq.gov/issue/adverse-events-women-giving-birth-labor-ward-retrospective-record-review-study
April 14, 2021 - Study
Adverse events in women giving birth in a labor ward: a retrospective record review study.
Citation Text:
Skoogh A, Hall-Lord ML, Bååth C, et al. Adverse events in women giving birth in a labor ward: a retrospective record review study. BMC Health Serv Res. 2021;21(1):1093. doi:10.…
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psnet.ahrq.gov/issue/improving-feedback-junior-doctors-prescribing-errors-mixed-methods-evaluation-quality
July 11, 2018 - Review
Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project.
Citation Text:
Reynolds M, Jheeta S, Benn J, et al. Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement proj…
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psnet.ahrq.gov/issue/transparency-public-reporting-and-culture-change-quality-and-safety-cardiac-surgery
February 17, 2021 - Commentary
Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.
Citation Text:
Ibrahim M, Szeto WY, Gutsche J, et al. Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery. Ann Thorac Surg. 2022;114(3…
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psnet.ahrq.gov/issue/intervention-decrease-patient-identification-band-errors-childrens-hospital
October 06, 2016 - Study
An intervention to decrease patient identification band errors in a children's hospital.
Citation Text:
Hain PD, Joers B, Rush M, et al. An intervention to decrease patient identification band errors in a children's hospital. Qual Saf Health Care. 2010;19(3):244-7. doi:10.1136/qs…
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psnet.ahrq.gov/issue/multicompartment-compliance-aids-community-prevalence-potentially-inappropriate-medications
January 30, 2013 - Study
Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications.
Citation Text:
Counter D, Stewart D, MacLeod J, et al. Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications. Br J Clin P…
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psnet.ahrq.gov/issue/development-and-implementation-subcutaneous-insulin-pen-label-bar-code-scanning-protocol
October 19, 2022 - Study
Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.
Citation Text:
MacMaster HW, Gonzalez S, Maruoka A, et al. Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning…
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psnet.ahrq.gov/issue/work-environment-and-operational-failures-associated-nurse-outcomes-patient-safety-and
March 17, 2021 - Study
Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction.
Citation Text:
Riman KA, Harrison JM, Sloane DM, et al. Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfac…