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psnet.ahrq.gov/node/46746/psn-pdf
March 07, 2018 - Safety with nebulized medications requires an
interdisciplinary team approach.
March 7, 2018
ISMP Medication Safety Alert! Acute care edition. February 22, 2018;23(4):1-5.
https://psnet.ahrq.gov/issue/safety-nebulized-medications-requires-interdisciplinary-team-approach
Myriad system and clinician failures can con…
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psnet.ahrq.gov/node/848825/psn-pdf
May 10, 2023 - Laura Levis' death outside ER has changed hospital
signage, lighting in Mass.
May 10, 2023
Mullins L, Menard F. WBUR. April 27, 2023.
https://psnet.ahrq.gov/issue/laura-levis-death-outside-er-has-changed-hospital-signage-lighting-mass
Incomplete information and building design problems can reduce access to care an…
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psnet.ahrq.gov/node/44298/psn-pdf
July 08, 2015 - Preparing challenging medications for barcode scanning.
July 8, 2015
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm.
2015;72(13):1089-90. doi:10.2146/ajhp140454.
https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
Barcode scanning can reduce me…
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psnet.ahrq.gov/node/42235/psn-pdf
June 03, 2013 - Surgical safety checklist: implementation in an
ambulatory surgical facility.
June 3, 2013
Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation in an ambulatory
surgical facility. Can J Anaesth. 2013;60(6):528-38. doi:10.1007/s12630-013-9916-8.
https://psnet.ahrq.gov/issue/surgical-sa…
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psnet.ahrq.gov/node/47994/psn-pdf
July 16, 2019 - What's in a name? Newborn naming conventions and
wrong-patient errors.
July 16, 2019
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
https://psnet.ahrq.gov/issue/whats-name-newborn-naming-conventions-and-wrong-patient-errors
Newborns assigned temporary names are at increased risk for patient misi…
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psnet.ahrq.gov/node/37117/psn-pdf
October 04, 2011 - Language barriers to prescriptions for patients with
limited English proficiency: a survey of pharmacies.
October 4, 2011
Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited
English proficiency: a survey of pharmacies. Pediatrics. 2007;120(2):e225-35.
https://psnet.a…
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psnet.ahrq.gov/node/74276/psn-pdf
January 19, 2022 - Guideline for Prevention of Unintentionally Retained
Surgical Items.
January 19, 2022
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6.
doi:10.1002/aorn.13579.
https://psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items
Retained su…
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psnet.ahrq.gov/node/60288/psn-pdf
April 29, 2020 - Do some surgical implants do more harm than good?
April 29, 2020
Groopman J. New Yorker Online. April 13, 2020.
https://psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
Medical devices support quality of life but must be designed appropriately and managed carefully to ensure
safety over time.…
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psnet.ahrq.gov/node/837430/psn-pdf
June 15, 2022 - Stop using these adult bed rails, warns the Consumer
Product Safety Commission.
June 15, 2022
Treisman R. National Public Radio. June 6, 2022
https://psnet.ahrq.gov/issue/stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission
Bedrails are used in hospitals and at home to minimize falls despite t…
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psnet.ahrq.gov/node/74756/psn-pdf
February 09, 2022 - Medication errors in overweight and obese pediatric
patients: a systematic review.
February 9, 2022
Procaccini D, Kim JM, Lobner K, et al. Medication errors in overweight and obese pediatric patients: a
systematic review. Jt Comm J Qual Patient Saf. 2022;48(3):154-164. doi:10.1016/j.jcjq.2021.12.005.
https://psnet…
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psnet.ahrq.gov/node/43118/psn-pdf
April 16, 2014 - NCPDP Recommendations and Guidance for
Standardizing the Dosing Designations on Prescription
Container Labels of Oral Liquid Medications Version 1.0.
April 16, 2014
Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014.
https://psnet.ahrq.gov/issue/ncpdp-recommendations-and-guidance-standardi…
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psnet.ahrq.gov/node/40287/psn-pdf
March 16, 2011 - The influence of 'Tall Man' lettering on errors of visual
perception in the recognition of written drug names.
March 16, 2011
Darker IT, Gerret D, Filik R, et al. The influence of 'Tall Man' lettering on errors of visual perception in the
recognition of written drug names. Ergonomics. 2011;54(1):21-33. doi:10.1080/…
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psnet.ahrq.gov/node/44990/psn-pdf
July 11, 2017 - Automatic errors: a case series on the errors inherent in
electronic prescribing.
July 11, 2017
Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic
Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5.
https://psnet.ahrq.gov/issue/automat…
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psnet.ahrq.gov/node/44531/psn-pdf
September 30, 2015 - Never Events for Hospital Care in Canada: Safer Care for
Patients.
September 30, 2015
Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN:
9781460666180.
https://psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients
The never events list was dev…
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psnet.ahrq.gov/node/43379/psn-pdf
August 14, 2014 - Unit of measurement used and parent medication dosing
errors.
August 14, 2014
Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors.
Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395.
https://psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosi…
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psnet.ahrq.gov/node/60192/psn-pdf
April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic
Health Records.
April 1, 2020
Philadelphia, PA: Pew Charitable Trusts; March 2020.
https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
Electronic health records both enhance and challenge the safety of care proce…
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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/47925/psn-pdf
August 21, 2019 - Second victims and mindfulness: a systematic review.
August 21, 2019
S Miller C, Scott SD, Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk
Manag. 2019;24(3):108-117. doi:10.1177/2516043519838176.
https://psnet.ahrq.gov/issue/second-victims-and-mindfulness-systematic-review
The secon…
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psnet.ahrq.gov/node/40992/psn-pdf
December 15, 2011 - Should patients get direct access to their laboratory test
results?: An answer with many questions.
December 15, 2011
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with
many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797.
https://psnet.ahrq…
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psnet.ahrq.gov/node/46701/psn-pdf
December 20, 2017 - The other big drug problem: older people taking too many
pills.
December 20, 2017
Boodman SG. Washington Post. December 9, 2017.
https://psnet.ahrq.gov/issue/other-big-drug-problem-older-people-taking-too-many-pills
The prevalence of polypharmacy among older patients represents an important concern for health care…