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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - The authors identified most errors in the prescribing stage, and older patients and children seem to
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - While some information coding standards are widely adopted and work well (e.g., standards that enable e-prescribing
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - complete and so unusual, it is far more likely to be in error than to reflect an idiosyncrasy of the prescribing
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - of Medicine
(IOM).(8)
As the country embarks on initiatives to increase the adoption of electronic prescribing
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Outpatient services were focused on reducing opioid prescribing, but not on the use of MAT for the treatment
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33577/psn-pdf
September 15, 2024 - residents until March 1984,
when 18-year-old Libby Zion died at New York Hospital due to a medication-prescribing
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psnet.ahrq.gov/issue/standardizing-hospital-discharge-planning-mayo-clinic
October 19, 2022 - Study
Standardizing hospital discharge planning at the Mayo Clinic.
Citation Text:
Holland DE, Hemann MA. Standardizing hospital discharge planning at the Mayo Clinic. Jt Comm J Qual Patient Saf. 2011;37(1):29-36.
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psnet.ahrq.gov/issue/fda-101-how-use-consumer-complaint-system-and-medwatch
February 15, 2024 - Fact Sheet/FAQs
FDA 101: How to Use the Consumer Complaint System and MedWatch.
Citation Text:
FDA 101: How to Use the Consumer Complaint System and MedWatch. FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 27, 2009.
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psnet.ahrq.gov/issue/2012-ismp-international-medication-safety-self-assessment-oncology
January 26, 2023 - Press Release/Announcement
2012 ISMP International Medication Safety Self Assessment for Oncology.
Citation Text:
2012 ISMP International Medication Safety Self Assessment for Oncology. Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada.
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psnet.ahrq.gov/issue/what-constitutes-effective-team-communication-after-error
September 23, 2020 - Commentary
What constitutes effective team communication after an error?
Citation Text:
Hart WM, Doerr P, Qian Y, et al. What constitutes effective team communication after an error? AMA J Ethics. 2020;22(4):E298-E304. doi:10.1001/amajethics.2020.298.
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psnet.ahrq.gov/issue/when-misdiagnosis-child-abuse
June 09, 2021 - Newspaper/Magazine Article
When the misdiagnosis is child abuse.
Citation Text:
Clifford S. When the misdiagnosis is child abuse. The Atlantic. 2020;August 20.
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psnet.ahrq.gov/issue/error-disclosure-pathology-and-laboratory-medicine-review-literature
July 28, 2021 - Review
Error disclosure in pathology and laboratory medicine: a review of the literature.
Citation Text:
Perkins IU. Error Disclosure in Pathology and Laboratory Medicine: A Review of the Literature. AMA J Ethics. 2016;18(8):809-16. doi:10.1001/journalofethics.2016.18.8.nlit1-1608.
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psnet.ahrq.gov/issue/negligence-genuine-error-and-litigation
July 10, 2024 - Review
Negligence, genuine error, and litigation.
Citation Text:
Sohn D. Negligence, genuine error, and litigation. Int J Gen Med. 2013. doi:10.2147/ijgm.s24256.
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psnet.ahrq.gov/issue/interview-lucian-leape
June 30, 2011 - Commentary
An interview with Lucian Leape.
Citation Text:
Schyve PM. An Interview with Lucian Leape. Jt Comm J Qual Patient Saf. 2016;30(12):653-658. doi:10.1016/s1549-3741(04)30076-6.
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psnet.ahrq.gov/issue/parents-perceptions-medical-errors
April 27, 2010 - Study
Parents' perceptions of medical errors.
Citation Text:
Mazor KM, Goff SL, Dodd KS, et al. Parents' Perceptions of Medical Errors. J Patient Saf. 2010;6(2). doi:10.1097/pts.0b013e3181ddfcd0.
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psnet.ahrq.gov/issue/preventing-overdiagnosis-how-stop-harming-healthy
January 02, 2013 - Commentary
Preventing overdiagnosis: how to stop harming the healthy.
Citation Text:
Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ. 2012;344:e3502. doi:10.1136/bmj.e3502.
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psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line
May 24, 2016 - Book/Report
Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice.
Citation Text:
Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. Carroll JS, R…
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psnet.ahrq.gov/issue/physician-perception-hospital-safety-and-barriers-incident-reporting
February 16, 2011 - Study
Physician perception of hospital safety and barriers to incident reporting.
Citation Text:
Schectman JM, Plews-Ogan M. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32(6):337-43.
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psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger
May 16, 2018 - Review
Surgical fires, a clear and present danger.
Citation Text:
Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon. 2010;8(2):87-92. doi:10.1016/j.surge.2010.01.005.
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