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psnet.ahrq.gov/node/47529/psn-pdf
January 21, 2019 - Community-acquired and hospital-acquired medication
harm among older inpatients and impact of a state-wide
medication management intervention.
January 21, 2019
Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm
among older inpatients and impact of a state-wide medica…
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psnet.ahrq.gov/node/41925/psn-pdf
November 26, 2014 - Medication reconciliation accuracy and patient
understanding of intended medication changes on
hospital discharge.
November 26, 2014
Ziaeian B, Araujo KLB, Van Ness PH, et al. Medication reconciliation accuracy and patient understanding
of intended medication changes on hospital discharge. J Gen Intern Med. 2012;2…
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psnet.ahrq.gov/node/836854/psn-pdf
April 06, 2022 - Medication discrepancy rates and sources upon nursing
home intake: a prospective study.
April 6, 2022
Patterson ME, Bollinger S, Coleman C, et al. Medication discrepancy rates and sources upon nursing
home intake: a prospective study. Res Social Adm Pharm. 2022;18(5):2830-2836.
doi:10.1016/j.sapharm.2021.06.013.
…
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psnet.ahrq.gov/node/61114/psn-pdf
November 11, 2020 - A mixed-methods analysis of patient safety incidents
involving opioid substitution treatment with methadone or
buprenorphine in community-based care in England and
Wales.
November 11, 2020
Gibson R, MacLeod N, Donaldson LJ, et al. A mixed?methods analysis of patient safety incidents involving
opioid substitution …
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psnet.ahrq.gov/node/857453/psn-pdf
December 06, 2023 - Post-implementation optimization of medication alerts in
hospital computerized provider order entry systems: a
scoping review.
December 6, 2023
Ledger TS, Brooke-Cowden K, Coiera E. Post-implementation optimization of medication alerts in hospital
computerized provider order entry systems: a scoping review. J Am M…
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psnet.ahrq.gov/node/46827/psn-pdf
March 14, 2018 - Prevalence and Economic Burden of Medication Errors in
the NHS England.
March 14, 2018
Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care
Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/61035/psn-pdf
October 21, 2020 - Children and the opioid epidemic: age-stratified
exposures and harms.
October 21, 2020
Brown KW, Carlisle K, Raman SR, et al. Children and the opioid epidemic: age-stratified exposures and
harms. Health Aff (Milwood). 2020;39(10):1737-1742. doi:10.1377/hlthaff.2020.00724.
https://psnet.ahrq.gov/issue/children-and-…
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Impact of prescribing guidelines for inpatient
anticoagulation.
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - May 29, 2024
Changes in early high-risk opioid prescribing practices after policy interventions
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psnet.ahrq.gov/node/47173/psn-pdf
June 06, 2018 - Pediatric ADHD medication exposures reported to US
poison control centers.
June 6, 2018
King SA, Casavant MJ, Spiller HA, et al. Pediatric ADHD Medication Exposures Reported to US Poison
Control Centers. Pediatrics. 2018;141(6). doi:10.1542/peds.2017-3872.
https://psnet.ahrq.gov/issue/pediatric-adhd-medication-exp…
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psnet.ahrq.gov/node/46948/psn-pdf
April 16, 2018 - Opioid-related critical care resource use in US children's
hospitals.
April 16, 2018
Kane JM, Colvin JD, Bartlett AH, et al. Opioid-Related Critical Care Resource Use in US Children's
Hospitals. Pediatrics. 2018;141(4):e20173335. doi:10.1542/peds.2017-3335.
https://psnet.ahrq.gov/issue/opioid-related-critical-care…
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psnet.ahrq.gov/node/41863/psn-pdf
November 21, 2012 - How reliable are patient-completed medication
reconciliation forms compared with pharmacy lists?
November 21, 2012
Meyer C, Stern M, Woolley W, et al. How reliable are patient-completed medication reconciliation forms
compared with pharmacy lists? Am J Emerg Med. 2012;30(7):1048-54. doi:10.1016/j.ajem.2011.06.038.
…
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psnet.ahrq.gov/node/42177/psn-pdf
November 23, 2016 - Failure to engage hospitalized elderly patients and their
families in advance care planning.
November 23, 2016
Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families
in advance care planning. JAMA Intern Med. 2013;173(9):778-787. doi:10.1001/jamainternmed.2013.18…
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
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psnet.ahrq.gov/node/836842/psn-pdf
April 07, 2022 - Assessing the impact of virtual medication history
technicians on medication reconciliation discrepancies.
April 7, 2022
Gadallah A, McGinnis B, Nguyen B, et al. Assessing the impact of virtual medication history technicians on
medication reconciliation discrepancies. Int J Clin Pharm. 2021;43(5):1404-1411. doi:10.…
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psnet.ahrq.gov/node/37622/psn-pdf
May 26, 2011 - Effect of computer order entry on prevention of serious
medication errors in hospitalized children.
May 26, 2011
Walsh KE, Landrigan CP, Adams WG, et al. Effect of computer order entry on prevention of serious
medication errors in hospitalized children. Pediatrics. 2008;121(3):e421-e427. doi:10.1542/peds.2007-
022…
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psnet.ahrq.gov/node/42577/psn-pdf
December 31, 2014 - Estimating the information gap between emergency
department records of community medication compared
to on-line access to the community-based pharmacy
records.
December 31, 2014
Tamblyn R, Poissant L, Huang A, et al. Estimating the information gap between emergency department
records of community medication compa…
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psnet.ahrq.gov/node/73121/psn-pdf
April 07, 2021 - The impact of introducing automated dispensing
cabinets, barcode medication administration, and closed-
loop electronic medication management systems on work
processes and safety of controlled medications in
hospitals: a systematic review.
April 7, 2021
Zheng WY, Lichtner V, Van Dort BA, et al. The impact of intr…
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - web-mm/weighty-mistake
https://psnet.ahrq.gov//#references
variability and complexity to medication prescribing … In addition to medication prescribing, pediatric clinicians titrate many
important medical interventions
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - some information coding standards are
widely adopted and work well (e.g., standards that enable e-prescribing