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psnet.ahrq.gov/node/45286/psn-pdf
May 07, 2018 - Paralyzed by mistakes: reassess the safety of
neuromuscular blockers in your facility.
May 7, 2018
ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6.
https://psnet.ahrq.gov/issue/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility
Neuromuscular blockers can result in seriou…
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psnet.ahrq.gov/node/60038/psn-pdf
March 11, 2020 - Errors associated with oxytocin use: a multi-organization
analysis by ISMP and ISMP Canada.
March 11, 2020
ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25(3):1-6.
https://psnet.ahrq.gov/issue/errors-associated-oxytocin-use-multi-organization-analysis-ismp-and-ismp-
canada
Errors in IV …
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psnet.ahrq.gov/node/44582/psn-pdf
January 23, 2017 - Chemotherapy regimen checks performed by pharmacists
contribute to safe administration of chemotherapy.
January 23, 2017
Suzuki S, Chan A, Nomura H, et al. Chemotherapy regimen checks performed by pharmacists contribute to
safe administration of chemotherapy. J Oncol Pract. 2017;23(1):18-25. doi:10.1177/10781552156…
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psnet.ahrq.gov/node/73958/psn-pdf
October 13, 2021 - Acting wisely in complex clinical situations: 'Mutual
safety' for clinicians as well as patients.
October 13, 2021
Dornan T, Lee C, Findlay-White F, et al. Acting wisely in complex clinical situations: ‘Mutual safety’ for
clinicians as well as patients. Med Teach. 2021;43(12):1419-1429. doi:10.1080/0142159x.2021.19…
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psnet.ahrq.gov/node/43470/psn-pdf
September 10, 2014 - Identifying critically ill patients at risk for inappropriate
antibiotic therapy: a pilot study of a point-of-care decision
support alert.
September 10, 2014
Micek ST, Heard KM, Gowan M, et al. Identifying critically ill patients at risk for inappropriate antibiotic
therapy: a pilot study of a point-of-care decisi…
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psnet.ahrq.gov/node/47432/psn-pdf
September 26, 2018 - Malnutrition in the hospital: the pharmacist’s role in
prevention and treatment.
September 26, 2018
Decerbo M. Pharmacy Practice News. September 13, 2018.
https://psnet.ahrq.gov/issue/malnutrition-hospital-pharmacists-role-prevention-and-treatment
Parenteral nutrition errors can result in patient malnutrition and …
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psnet.ahrq.gov/node/851067/psn-pdf
June 28, 2023 - Assessing medication safety in settings not designated
solely for pediatric patients.
June 28, 2023
ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5.
https://psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
Pediatric patients are at increa…
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psnet.ahrq.gov/node/43153/psn-pdf
May 07, 2014 - Is oral chemotherapy prescription safe for patients? A
cross-sectional survey.
May 7, 2014
Bourmaud A, Pacaut C, Melis A, et al. Is oral chemotherapy prescription safe for patients? A cross-
sectional survey. Ann Oncol. 2014;25(2):500-504. doi:10.1093/annonc/mdt553.
https://psnet.ahrq.gov/issue/oral-chemotherapy-p…
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psnet.ahrq.gov/node/45597/psn-pdf
December 14, 2016 - An E.R. kicks the habit of opioids for pain.
December 14, 2016
Hoffman J. New York Times. June 10, 2016.
https://psnet.ahrq.gov/issue/er-kicks-habit-opioids-pain
Overprescribing of opioids for pain management contributes to the growing crisis involving opioid-related
harm. This newspaper article reports on one hos…
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psnet.ahrq.gov/node/841488/psn-pdf
December 14, 2022 - ASHP Guidelines on Preventing Diversion of Controlled
Substances.
December 14, 2022
Clark J, Fera T, Fortier CR, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am
J Health Syst Pharm. 2022;79(24):2279-2306. doi:10.1093/ajhp/zxac246.
https://psnet.ahrq.gov/issue/ashp-guidelines-preventing-…
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psnet.ahrq.gov/node/45993/psn-pdf
January 01, 2021 - 30-day potentially avoidable readmissions due to adverse
drug events.
May 3, 2017
Dalleur O, Beeler PE, Schnipper JL, et al. 30-Day Potentially Avoidable Readmissions Due to Adverse
Drug Events. J Patient Saf. 2021;17(5):e379-e386. doi:10.1097/pts.0000000000000346.
https://psnet.ahrq.gov/issue/30-day-potentially-a…
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psnet.ahrq.gov/node/43606/psn-pdf
October 15, 2014 - Opioids for chronic noncancer pain: a position paper of
the American Academy of Neurology.
October 15, 2014
Franklin GM, Neurology AA of. Opioids for chronic noncancer pain: a position paper of the American
Academy of Neurology. Neurology. 2014;83(14):1277-84. doi:10.1212/WNL.0000000000000839.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/40456/psn-pdf
May 18, 2011 - Medication assessments by care managers reveal
potential safety issues in homebound older adults.
May 18, 2011
Golden AG, Qiu D, Roos BA. Medication assessments by care managers reveal potential safety issues in
homebound older adults. Ann Pharmacother. 2011;45(4):492-8. doi:10.1345/aph.1P643.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/46686/psn-pdf
January 31, 2018 - Case not closed: prescription errors 12 years after
computerized physician order entry implementation.
January 31, 2018
Kadmon G, Pinchover M, Weissbach A, et al. Case Not Closed: Prescription Errors 12 Years after
Computerized Physician Order Entry Implementation. J Pediatr. 2017;190:236-240.e2.
doi:10.1016/j.jpe…
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psnet.ahrq.gov/node/47222/psn-pdf
October 03, 2018 - Decision support tools, systems, and artificial intelligence
in cardiac imaging.
October 3, 2018
Massalha S, Clarkin O, Thornhill R, et al. Decision Support Tools, Systems, and Artificial Intelligence in
Cardiac Imaging. Can J Cardiol. 2018;34(7):827-838. doi:10.1016/j.cjca.2018.04.032.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/47850/psn-pdf
March 27, 2019 - Medicines-related harm in the elderly post-hospital
discharge.
March 27, 2019
Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34.
https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge
Geriatric patients are particularly vulnerable to medication-related harm. This articl…
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psnet.ahrq.gov/node/50673/psn-pdf
November 20, 2019 - The introduction of a Neurosurgical Postoperative
Checklist improved quality of care and patient safety.
November 20, 2019
Hall AJ, Toner NS, Bhatt PM. The introduction of a Neurosurgical Postoperative Checklist improved quality
of care and patient safety. Br J Neurosurg. 2019;33(5):495-499. doi:10.1080/02688697.20…
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psnet.ahrq.gov/node/46813/psn-pdf
March 14, 2018 - Our other prescription drug problem.
March 14, 2018
Lembke A, Papac J, Humphreys K. Our Other Prescription Drug Problem. N Engl J Med. 2018;378(8):693-
695. doi:10.1056/NEJMp1715050.
https://psnet.ahrq.gov/issue/our-other-prescription-drug-problem
Unintended consequences can emerge when targeted strategies divert …
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/womenhealth/2014nhqdr-womenhealth.pptx
January 01, 2020 - Prescription medications received include all prescribed medications initially purchased or otherwise … Importance: Some drugs that are prescribed for older patients are known to be potentially harmful for … From 2002 to 2012, the percentage of men age 65 and over who were prescribed at least 1 medication from … Groups With Disparities: In all years from 2002 to 2012, men were less likely than women to be prescribed … Some adverse events, such as known side effects of appropriately prescribed medications, may be unavoidable
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - hospitals have implemented institutional warfarin dosing policies that require the medication to be prescribed