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psnet.ahrq.gov/node/47423/psn-pdf
January 27, 2019 - A health system–wide initiative to decrease opioid-related
morbidity and mortality.
January 27, 2019
Weiner SG, Price CN, Atalay AJ, et al. A Health System-Wide Initiative to Decrease Opioid-Related
Morbidity and Mortality. Jt Comm J Qual Patient Saf. 2019;45(1):3-13. doi:10.1016/j.jcjq.2018.07.003.
https://psnet.…
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psnet.ahrq.gov/node/48171/psn-pdf
August 21, 2019 - Reducing drug prescription errors and adverse drug
events by application of a probabilistic, machine-learning
based clinical decision support system in an inpatient
setting.
August 21, 2019
Segal G, Segev A, Brom A, et al. Reducing drug prescription errors and adverse drug events by application
of a probabilistic…
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psnet.ahrq.gov/node/41606/psn-pdf
February 01, 2019 - Safe use of opioids in hospitals.
December 23, 2016
Sentinel Event Alert. 2012;49:1-5.
https://psnet.ahrq.gov/issue/safe-use-opioids-hospitals
Opioid pain medications are considered high-risk medications due to the potential for respiratory
depression and other adverse effects. Because these medications are freque…
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psnet.ahrq.gov/node/46395/psn-pdf
September 06, 2017 - Deprescribing: a simple method for reducing
polypharmacy.
September 6, 2017
McGrath K, Hajjar ER, Kumar C, et al. Deprescribing: A simple method for reducing polypharmacy. J Fam
Pract. 2017;66(7):436-445. https://www.mdedge.com/familymedicine/article/141753/practice-
management/deprescribing-simple-method-reducing…
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psnet.ahrq.gov/node/845633/psn-pdf
March 08, 2023 - Impact of pharmacist interventions provided in the
emergency department on quality use of medicines: a
systematic review and meta-analysis.
March 8, 2023
Atey TM, Peterson GM, Salahudeen MS, et al. Impact of pharmacist interventions provided in the
emergency department on quality use of medicines: a systematic rev…
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psnet.ahrq.gov/node/44579/psn-pdf
September 01, 2016 - Increased appropriateness of customized alert
acknowledgement reasons for overridden medication
alerts in a computerized provider order entry system.
September 1, 2016
Dekarske BM, Zimmerman CR, Chang R, et al. Increased appropriateness of customized alert
acknowledgement reasons for overridden medication alerts i…
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psnet.ahrq.gov/node/866323/psn-pdf
July 17, 2024 - AHRQ-Funded Patient Safety Project Highlights:
Improving Patient Safety by Enhancing Care
Coordination.
July 17, 2024
Rockville, MD: Agency for Healthcare Research and Quality; June 2024. AHRQ Pub. No. 24-0017-2-EF.
https://psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-patient-safety…
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psnet.ahrq.gov/node/60947/psn-pdf
September 23, 2020 - FDA Advise-ERR: reported medication errors with Veklury
(remdesivir) emergency use authorization.
September 23, 2020
ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)
https://psnet.ahrq.gov/issue/fda-advise-err-reported-medication-errors-veklury-remdesivir-emergency-use-
authorizatio…
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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
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psnet.ahrq.gov/node/60046/psn-pdf
March 18, 2020 - Adverse outcomes of polypharmacy in older people:
systematic review of reviews.
March 18, 2020
Davies LE, Spiers G, Kingston A, et al. Adverse outcomes of polypharmacy in older people: systematic
review of reviews. J Am Med Dir Assoc. 2020;21(2):181-187. doi:10.1016/j.jamda.2019.10.022.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/866585/psn-pdf
August 28, 2024 - Sex bias in pain management decisions.
August 28, 2024
Guzikevits M, Gordon-Hecker T, Rekhtman D, et al. Sex bias in pain management decisions. Proc Natl
Acad Sci U S A. 2024;121(33):e2401331121. doi:10.1073/pnas.2401331121.
https://psnet.ahrq.gov/issue/sex-bias-pain-management-decisions
Bias against women is, unf…
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psnet.ahrq.gov/node/72569/psn-pdf
January 01, 2021 - Risk factors associated with medication ordering errors.
December 16, 2020
Abraham J, Galanter WL, Touchette DR, et al. Risk factors associated with medication ordering errors. J
Am Med Inform Assoc. 2021;18(1):86-94. doi:10.1093/jamia/ocaa264.
https://psnet.ahrq.gov/issue/risk-factors-associated-medication-orderin…
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psnet.ahrq.gov/node/36496/psn-pdf
February 28, 2011 - Literacy and misunderstanding prescription drug labels.
February 28, 2011
Davis TC, Wolf MS, Bass PF, et al. Literacy and misunderstanding prescription drug labels. Ann Intern
Med. 2006;145(12):887-94.
https://psnet.ahrq.gov/issue/literacy-and-misunderstanding-prescription-drug-labels
Poor health literacy has been…
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psnet.ahrq.gov/node/60018/psn-pdf
March 04, 2020 - 2019 update on pediatric medical overuse: a systematic
review.
March 4, 2020
Money NM, Schroeder AR, Quinonez RA, et al. 2019 Update on Pediatric Medical Overuse. JAMA Pediatr.
2020;174(4):375-382. doi:10.1001/jamapediatrics.2019.5849.
https://psnet.ahrq.gov/issue/2019-update-pediatric-medical-overuse-systematic-r…
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psnet.ahrq.gov/node/47995/psn-pdf
July 24, 2019 - Standardising the classification of harm associated with
medication errors: the Harm Associated with Medication
Error Classification (HAMEC).
July 24, 2019
Gates PJ, Baysari M, Mumford V, et al. Standardising the Classification of Harm Associated with
Medication Errors: The Harm Associated with Medication Error Cl…
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psnet.ahrq.gov/node/837801/psn-pdf
August 10, 2022 - Decreasing misdiagnoses of urinary tract infections in a
pediatric emergency department.
August 10, 2022
Ostrow O, Prodanuk M, Foong Y, et al. Decreasing misdiagnoses of urinary tract infections in a pediatric
emergency department. Pediatrics. 2022;150(1):e2021055866. doi:10.1542/peds.2021-055866.
https://psnet.ah…
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psnet.ahrq.gov/node/47326/psn-pdf
August 29, 2018 - Trends in opioid use in commercially insured and
Medicare Advantage populations in 2007–16:
retrospective cohort study.
August 29, 2018
Jeffery MM, Hooten M, Henk HJ, et al. Trends in opioid use in commercially insured and Medicare
Advantage populations in 2007-16: retrospective cohort study. BMJ. 2018;362:k2833.
…
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psnet.ahrq.gov/node/46364/psn-pdf
September 24, 2017 - Exploring the potential for using drug indications to
prevent look-alike and sound-alike drug errors.
September 24, 2017
Seoane-Vazquez E, Rodriguez-Monguio R, Alqahtani S, et al. Exploring the potential for using drug
indications to prevent look-alike and sound-alike drug errors. Expert Opin Drug Saf. 2017;16(10):…
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psnet.ahrq.gov/node/836776/psn-pdf
March 23, 2022 - Potentially inappropriate medications and their effect on
falls during hospital admission.
March 23, 2022
Damoiseaux-Volman BA, Raven K, Sent D, et al. Potentially inappropriate medications and their effect on
falls during hospital admission. Age Ageing. 2022;51(1):afab205. doi:10.1093/ageing/afab205.
https://psne…
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psnet.ahrq.gov/node/73209/psn-pdf
May 05, 2021 - Medication incident recovery and prevention utilising an
Australian community pharmacy incident reporting
system: the QUMwatch study.
May 5, 2021
Adie K, Fois RA, McLachlan AJ, et al. Medication incident recovery and prevention utilising an Australian
community pharmacy incident reporting system: the QUMwatch stud…