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psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - physicians found that use of accountable justification (providers had to
enter free-text justifications for prescribing … antibiotics) and peer comparison resulted in lower rates of
inappropriate antibiotic prescribing for … Effect of behavioral interventions on inappropriate antibiotic
prescribing among primary care practices
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - Another way to mitigate this risk is by standardizing opioid prescribing patterns, leveraging technology … Standardizing opioid prescribing patterns via order sets and institutional guidelines allows everyone … Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting
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psnet.ahrq.gov/node/33817/psn-pdf
October 01, 2016 - Health Care Data Science for Quality Improvement and
Patient Safety
October 1, 2016
Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
Perspective
Background
Ha…
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - substituted for the insulin vial containing the same active ingredient without the intervention of the prescribing … Improving the quality of insulin prescribing for people with diabetes being discharged from hospital.
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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - complex system of scores of
individual tasks that can be categorized into five stages: ordering or prescribing … medication safety.(2)
Research has shown that most medication errors are made by providers during the prescribing
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - objective data
regarding drug-seeking behavior (7), and racial and ethnic biases play a role in our opioid prescribing … Controlled substance prescribing patterns—prescription behavior surveillance system, eight states, 2013
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - substituted for the insulin vial containing the same active ingredient without the intervention of the
prescribing … Improving the quality of insulin prescribing for people with
diabetes being discharged from hospital
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - This article describes ongoing challenges (e.g., workforce limitations, polypharmacy) faced by safe prescribing … practices and emerging approaches (such as artificial intelligence) that can advance medication and prescribing
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/45932/psn-pdf
May 18, 2017 - Polypharmacy.
May 18, 2017
Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292.
https://psnet.ahrq.gov/issue/polypharmacy
Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this
special issue explore polypharmacy in a variety of care settings and provide tactics f…
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psnet.ahrq.gov/node/42975/psn-pdf
February 26, 2014 - State-Wide Initiative to Standardize the Compounding of
Oral Liquids in Pediatrics.
February 26, 2014
Michigan Pharmacists Association; MPA.
https://psnet.ahrq.gov/issue/state-wide-initiative-standardize-compounding-oral-liquids-pediatrics
Children are often prescribed oral liquid medications due to difficulty swa…
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psnet.ahrq.gov/node/49600/psn-pdf
April 01, 2010 - Bad Writing, Wrong Medication
April 1, 2010
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
Case Objectives
Differentiate between a medication error and an adverse drug event.
Appreciate the system complexities involved in medication erro…
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/node/44232/psn-pdf
January 29, 2019 - Optimizing medication safety in the home.
January 29, 2019
LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthc Now. 2015;33(6):313-319.
doi:10.1097/NHH.0000000000000246.
https://psnet.ahrq.gov/issue/optimizing-medication-safety-home
Patients who receive home care services are vulnerable to a…
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psnet.ahrq.gov/node/34903/psn-pdf
September 02, 2016 - Promethazine adverse events after implementation of a
medication shortage interchange.
September 2, 2016
Sheth HS, Verrico MM, Skledar S, et al. Promethazine adverse events after implementation of a medication
shortage interchange. Ann Pharmacother. 2005;39(2):255-61.
https://psnet.ahrq.gov/issue/promethazine-adve…
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psnet.ahrq.gov/node/42777/psn-pdf
December 11, 2013 - Risk of medication safety incidents with antibiotic use
measured by defined daily doses.
December 11, 2013
Hamad A, Cavell G, Wade P, et al. Risk of medication safety incidents with antibiotic use measured by
defined daily doses. Int J Clin Pharm. 2013;35(5):772-9. doi:10.1007/s11096-013-9805-9.
https://psnet.ahrq…
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psnet.ahrq.gov/node/44349/psn-pdf
July 22, 2015 - Popular blood thinner causing deaths, injuries in nursing
homes.
July 22, 2015
https://psnet.ahrq.gov/issue/popular-blood-thinner-causing-deaths-injuries-nursing-homes
Anticoagulants are considered high-alert medications that if used ineffectively can result in patient harm.
Reporting on an anticoagulant commonly …
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psnet.ahrq.gov/perspective/response-failure-report-march-2007
June 01, 2007 - April 22, 2017
Automated detection of wrong-drug prescribing errors.
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - Prescribing errors on admission to hospital and their potential impact: a mixed-methods study.
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psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa
June 29, 2023 - June 22, 2022
Medicines reconciliation in the emergency department: important prescribing