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2221. JCAHO tightens leash on medication reconciliation. | PSNet
      psnet.ahrq.gov/issue/jcaho-tightens-leash-medication-reconciliation
      April 12, 2006 - Newspaper/Magazine Article JCAHO tightens leash on medication reconciliation. Citation Text: JCAHO tightens leash on medication reconciliation. Perry LE. Drug Topics. March 20, 2006. Copy Citation Save Save to your library Print Download PDF S…

2222. Organizing for Reliability: A Guide for Research and Practice. | PSNet
      psnet.ahrq.gov/issue/organizing-reliability-guide-research-and-practice
      April 01, 2020 - Book/Report Organizing for Reliability: A Guide for Research and Practice. Citation Text: Organizing for Reliability: A Guide for Research and Practice. Ramanujam R, Roberts KH, eds. Stanford, CA: Stanford University Press; 2018. ISBN: 9780804793612. Copy Citation Save …

2223. The paradoxes of defensive medicine. | PSNet
      psnet.ahrq.gov/issue/paradoxes-defensive-medicine
      June 08, 2022 - Commentary The paradoxes of defensive medicine. Citation Text: The paradoxes of defensive medicine. Saks MJ, Landsman S. Health Matrix: J Law-Med. 2020;30(1):25-84. Copy Citation Save Save to your library Print Download PDF Share Facebook …

2224. NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action. | PSNet
      psnet.ahrq.gov/issue/ny-medicaid-ups-ante-refusing-pay-14-never-events-nations-biggest-medicaid-program-could
      December 16, 2009 - Newspaper/Magazine Article NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action. Citation Text: NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid p…

2225. Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. | PSNet
      psnet.ahrq.gov/issue/results-ismp-survey-high-alert-medications-differences-between-nursing-pharmacy-and
      March 14, 2023 - Newspaper/Magazine Article Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. Citation Text: Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspe…

2226. Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. | PSNet
      psnet.ahrq.gov/issue/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry-errors
      June 10, 2018 - Newspaper/Magazine Article Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. Citation Text: Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. ISMP Medication Safety Alert! Acute care…

2227. Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? | PSNet
      psnet.ahrq.gov/issue/side-tracks-safety-express-interruptions-lead-errors-and-unfinishedwait-what-was-i-doing
      June 10, 2018 - Newspaper/Magazine Article Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? Citation Text: Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? ISMP Medication Safety Alert! Acute care…

2228. A shortage of everything except errors: harm associated with drug shortages. | PSNet
      psnet.ahrq.gov/issue/shortage-everything-except-errors-harm-associated-drug-shortages
      February 13, 2019 - Newspaper/Magazine Article A shortage of everything except errors: harm associated with drug shortages. Citation Text: A shortage of everything except errors: harm associated with drug shortages. ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3. Copy Citation …

2229. Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. | PSNet
      psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-leading-drug
      June 10, 2018 - Newspaper/Magazine Article Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. Citation Text: Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety…

2230. Raising the index of suspicion: red flags that represent credible threats to patient safety. | PSNet
      psnet.ahrq.gov/issue/raising-index-suspicion-red-flags-represent-credible-threats-patient-safety
      February 13, 2019 - Newspaper/Magazine Article Raising the index of suspicion: red flags that represent credible threats to patient safety. Citation Text: Raising the index of suspicion: red flags that represent credible threats to patient safety. ISMP Medication Safety Alert! Acute Care Edition. July 26, 2…

2231. The REPAIR Project. | PSNet
      psnet.ahrq.gov/issue/repair-project
      March 27, 2005 - Multi-use Website The REPAIR Project. Citation Text: The REPAIR Project. University of California San Francisco, San Francisco, CA. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin …

2232. Sustaining Improvement. | PSNet
      psnet.ahrq.gov/issue/sustaining-improvement
      January 09, 2019 - Book/Report Sustaining Improvement. Citation Text: Sustaining Improvement. Scoville R, Little K, Rakover J, et al. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. Copy Citation Save Save to your library Print Download PDF S…

2233. Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008. | PSNet
      psnet.ahrq.gov/issue/medication-related-adverse-outcomes-us-hospitals-and-emergency-departments-2008
      September 15, 2010 - Book/Report Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008. Citation Text: Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008. Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency …

2234. Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report. | PSNet
      psnet.ahrq.gov/issue/improving-measurement-surgical-site-infection-risk-stratificationoutcome-detection-final
      August 01, 2012 - Book/Report Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report. Citation Text: Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report. Price CS, Savitz LA. Rockville,…

2235. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-systems-patients-limited-english-proficiency-guide-hospitals
      August 01, 2012 - Book/Report Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals. Citation Text: Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals. Rockville, MD: Agency for Healthcare Research and Quali…

2236. Drug name confusion: preventing medication errors. | PSNet
      psnet.ahrq.gov/issue/drug-name-confusion-preventing-medication-errors
      January 29, 2018 - Newspaper/Magazine Article Drug name confusion: preventing medication errors. Citation Text: Rados C. Drug name confusion: preventing medication errors. FDA consumer. 2005;39(4):35-7. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …

2237. Novant Health Uses AHRQ Tool to Assess and Improve Patient Communications | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/201602.html
      April 01, 2016 - Novant Health Uses AHRQ Tool to Assess and Improve Patient Communications Search All Impact Case Studies April 2016 Winston-Salem, N.C.-based Novant Health, the nation's fifth largest medical group, used AHRQ's Patient Education Materials Assessment Tool (PEMAT) to rework its patient education materials a…

2238. Developing a medication patient safety program, part 2: process and implementation. | PSNet
      psnet.ahrq.gov/issue/developing-medication-patient-safety-program-part-2-process-and-implementation
      May 11, 2014 - Commentary Developing a medication patient safety program, part 2: process and implementation. Citation Text: Developing a medication patient safety program, part 2: process and implementation. Mark SM, Weber RJ. Hosp Pharm. 2007;42(3):249-254. Copy Citation Save …

2239. "Use as directed" can cause confusion for both patients and practitioners. | PSNet
      psnet.ahrq.gov/issue/use-directed-can-cause-confusion-both-patients-and-practitioners
      August 24, 2016 - Newspaper/Magazine Article "Use as directed" can cause confusion for both patients and practitioners. Citation Text: "Use as directed" can cause confusion for both patients and practitioners. ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3. Copy Citation …

2240. Patient Safety in Ambulatory Settings: Technical Brief. | PSNet
      psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
      September 29, 2017 - Book/Report Patient Safety in Ambulatory Settings: Technical Brief. Citation Text: Patient Safety in Ambulatory Settings: Technical Brief. Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016. Copy Citation Save …