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psnet.ahrq.gov/web-mm/missing-point-eye-injury
March 01, 2005 - Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Cases
Diagnosing Diagnostic Mistakes
May 1, 2005
Opioid prescribing
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - January 15, 2020
Inappropriate prescribing of opioids for patients undergoing surgery
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psnet.ahrq.gov/web-mm/sloppy-and-paste
February 02, 2011 - and Treating Delirium in the Intensive Care Unit
December 1, 2012
Opioid prescribing
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - Selling more requires doctors
to use more of their products in surgeries, tests, and prescribing practices
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psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
February 01, 2014 - while in traffic or when a health care professional is interrupted during a high-risk task such as prescribing … system improvements; (viii) managing alerts, alarms, and noise; and (ix) gathering supplies prior to prescribing
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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psnet.ahrq.gov/node/49743/psn-pdf
September 01, 2015 - Dual Therapy Debacle
September 1, 2015
Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/dual-therapy-debacle
The Case
An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction,
hyperlipidemia, obesity, and a long history of tobacco use …
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Human Factors Engineering Can Teach You How to Be
Surprised Again
November 1, 2006
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
Perspective
Certain phrases ar…
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - Resources From the Same Author(s)
STOPP/START criteria for potentially inappropriate prescribing
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - Medication Handling and Compounding Errors in the
Operating Room.
March 15, 2023
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating
Room. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
The Case
A 62-y…
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Dispensing Errors
(5)
Monitoring Errors and Failures
(4)
Ordering/Prescribing
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - We know that errors in prescribing, dispensing, and administering medications represent a
substantial
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - December 7, 2022
Factors associated with potentially harmful medication prescribing in nursing homes
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - concentrations in drug libraries intended for IV infusions.( 6 ) Finally, there is significant variability in prescribing