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psnet.ahrq.gov/node/43366/psn-pdf
March 04, 2015 - Safety of medication use in primary care.
March 4, 2015
Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract.
2015;23(1):3-20. doi:10.1111/ijpp.12120.
https://psnet.ahrq.gov/issue/safety-medication-use-primary-care
This systematic review found that incidence rates of…
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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psnet.ahrq.gov/node/44193/psn-pdf
August 05, 2015 - Pediatric emergency department discharge prescriptions
requiring pharmacy clarification.
August 5, 2015
Caruso MC, Gittelman MA, Widecan ML, et al. Pediatric emergency department discharge prescriptions
requiring pharmacy clarification. Pediatr Emerg Care. 2015;31(6):403-8.
doi:10.1097/PEC.0000000000000457.
https…
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psnet.ahrq.gov/node/37262/psn-pdf
December 19, 2011 - Academic detailing to improve laboratory testing among
outpatient medication users.
December 19, 2011
Lafata JE, Gunter MJ, Hsu J, et al. Academic detailing to improve laboratory testing among outpatient
medication users. Med Care. 2007;45(10):966-72.
https://psnet.ahrq.gov/issue/academic-detailing-improve-laborat…
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psnet.ahrq.gov/node/43819/psn-pdf
July 16, 2015 - Intercepting wrong-patient orders in a computerized
provider order entry system.
July 16, 2015
Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider
order entry system. Ann Emerg Med. 2015;65(6):679-686.e1. doi:10.1016/j.annemergmed.2014.11.017.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/38498/psn-pdf
September 27, 2016 - Nursing time devoted to medication administration in
long-term care: clinical, safety, and resource implications.
September 27, 2016
Thomson MS, Gruneir A, Lee M, et al. Nursing time devoted to medication administration in long-term care:
clinical, safety, and resource implications. J Am Geriatr Soc. 2009;57(2):266…
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psnet.ahrq.gov/node/45007/psn-pdf
March 30, 2016 - Medication errors involving healthcare students.
March 30, 2016
Hess L, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. March 2016;13:18-23.
https://psnet.ahrq.gov/issue/medication-errors-involving-healthcare-students
Using reports of medication errors submitted to the Pennsylvania Patient Safety Authority that …
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psnet.ahrq.gov/node/854637/psn-pdf
October 18, 2023 - A scoping review of clinical handover mnemonic devices.
October 18, 2023
Yung AHW, Pak CS, Watson B. A scoping review of clinical handover mnemonic devices. Int J Qual Health
Care. 2023;35(3):mzad065. doi:10.1093/intqhc/mzad065.
https://psnet.ahrq.gov/issue/scoping-review-clinical-handover-mnemonic-devices
Cogniti…
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psnet.ahrq.gov/node/42556/psn-pdf
August 28, 2013 - Findings and Lessons From the Improving Quality
Through Clinician Use of Health IT Grant Initiative.
August 28, 2013
Rockville, MD: Agency for Healthcare Research and Quality. May 2013. AHRQ Publication No 13-0042-EF.
https://psnet.ahrq.gov/issue/findings-and-lessons-improving-quality-through-clinician-use-health-i…
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psnet.ahrq.gov/node/36690/psn-pdf
January 18, 2011 - The risk of adverse drug events and hospital-related
morbidity and mortality among older adults with
potentially inappropriate medication use.
January 18, 2011
Page RL, Ruscin M. The risk of adverse drug events and hospital-related morbidity and mortality among
older adults with potentially inappropriate medicatio…
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Temporarily holding medication orders safely in order to
prevent patient harm.
November 1, 2023
ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.
https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
Process disconnects can cause administr…
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psnet.ahrq.gov/node/838254/psn-pdf
October 05, 2022 - Embedded bias: how medical records sow discrimination.
October 5, 2022
Tahir D. Kaiser Health News. September 26, 2022.
https://psnet.ahrq.gov/issue/embedded-bias-how-medical-records-sow-discrimination
Negative patient representations in medical records perpetuate stereotypes that can affect care over ti…
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psnet.ahrq.gov/node/41273/psn-pdf
June 01, 2012 - Minimizing inappropriate medications in older
populations: a ten-step conceptual framework.
June 1, 2012
Scott IA, Gray LC, Martin J, et al. Minimizing inappropriate medications in older populations: a 10-step
conceptual framework. Am J Med. 2012;125(6):529-37.e4. doi:10.1016/j.amjmed.2011.09.021.
https://psnet.ah…
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psnet.ahrq.gov/node/74762/psn-pdf
February 09, 2022 - Start the year off right by addressing these top 10
medication safety concerns from 2021.
February 9, 2022
ISMP Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.
https://psnet.ahrq.gov/issue/start-year-right-addressing-these-top-10-medication-safety-concerns-2021
Medication errors are a cons…
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psnet.ahrq.gov/node/45560/psn-pdf
October 19, 2016 - Learning from excellence in healthcare: a new approach
to incident reporting.
October 19, 2016
Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting.
Arch Dis Child. 2016;101(9):788-791. doi:10.1136/archdischild-2015-310021.
https://psnet.ahrq.gov/issue/learning…
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psnet.ahrq.gov/node/35502/psn-pdf
May 27, 2011 - Medication errors: a prospective cohort study of hand-
written and computerised physician order entry in the
intensive care unit.
May 27, 2011
Shulman R, Singer M, Goldstone J, et al. Medication errors: a prospective cohort study of hand-written and
computerised physician order entry in the intensive care unit. Cr…
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psnet.ahrq.gov/node/43464/psn-pdf
August 27, 2014 - Using pharmacists to optimize patient outcomes and
costs in the ED.
August 27, 2014
Jacknin G, Nakamura T, Smally AJ, et al. Using pharmacists to optimize patient outcomes and costs in the
ED. Am J Emerg Med. 2014;32(6):673-7. doi:10.1016/j.ajem.2013.11.031.
https://psnet.ahrq.gov/issue/using-pharmacists-optimize-…
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psnet.ahrq.gov/node/46791/psn-pdf
May 23, 2018 - Medication Safety Dashboard.
May 23, 2018
National Health Service.
https://psnet.ahrq.gov/issue/medication-safety-dashboard
Data surveillance and transparency are core to measuring and informing improvement efforts. This website
provides detailed data that links ambulatory care prescribing activity to National Hea…
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psnet.ahrq.gov/node/40029/psn-pdf
November 24, 2010 - Formal medicine reconciliation within the emergency
department reduces the medication error rates for
emergency admissions.
November 24, 2010
Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the
medication error rates for emergency admissions. Emerg Med J. 2010;27(12):9…
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psnet.ahrq.gov/node/44574/psn-pdf
October 21, 2015 - Patient safety and quality improvement: reducing risk of
harm.
October 21, 2015
Leonard M. Patient Safety and Quality Improvement: Reducing Risk of Harm. Pediatr Rev.
2015;36(10):448-56; quiz 457-8. doi:10.1542/pir.36-10-448.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-reducing-risk-harm
T…