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psnet.ahrq.gov/issue/dosing-errors-made-paramedics-during-pediatric-patient-simulations-after-implementation-state
August 25, 2021 - paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference … Paramedics During Pediatric Patient Simulations After Implementation of a State-Wide Pediatric Drug Dosing Reference … This study found that in simulations, Michigan's state-wide pediatric dosing reference system reduced … Paramedics During Pediatric Patient Simulations After Implementation of a State-Wide Pediatric Drug Dosing Reference … prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/issue/analysis-prehospital-pediatric-medication-dosing-errors-after-implementation-state-wide-ems
August 25, 2021 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference … prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference … age and younger after implementation of a statewide emergency medical services (EMS) pediatric dosing reference … prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/shared-libraries
May 19, 2025 - Registered PSNet users can create private libraries to house collections of PSNet content for easy reference
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psnet.ahrq.gov/issue/variability-diagnostic-error-rates-10-mri-centers-performing-lumbar-spine-mri-examinations
March 14, 2022 - underwent the same MRI exam at 10 local centers, plus one before and after at the author’s institution (reference … Although each exam included at least one finding from the reference MRI, there was variability in the
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psnet.ahrq.gov/node/845297/psn-pdf
January 01, 2024 - pediatric medication dosing
errors after implementation of a state-wide EMS pediatric
drug dosing reference … pediatric medication dosing errors after
implementation of a state-wide EMS pediatric drug dosing reference … and younger after implementation of a statewide emergency medical services
(EMS) pediatric dosing reference
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psnet.ahrq.gov/node/48109/psn-pdf
January 01, 2020 - paramedics during pediatric
patient simulations after implementation of a state-wide
pediatric drug dosing reference … Paramedics During Pediatric Patient
Simulations After Implementation of a State-Wide Pediatric Drug Dosing Reference … This study found that in simulations, Michigan's state-wide pediatric dosing reference
system reduced
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psnet.ahrq.gov/issue/medical-research-and-institutional-review-board-librarians-role-human-subject-testing
June 01, 2022 - Reference Services Review. 2005;33(1);
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Save to your library … Reference Services Review. 2005;33(1);
View more articles from the same authors. … Reference Services Review. 2005;33(1);
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Related Resources From the Same … prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/issue/decreasing-prescribing-errors-during-pediatric-emergencies-randomized-simulation-trial
October 08, 2013 - This simulation study randomized residents in a pediatric emergency department to receive either a reference … paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - . 2003
Reference 4
PROWESS Study
Large multicenter, randomized, placebo-controlled trial (PROWESS … Reference 4
PROWESS Inclusion
Included patients with known or suspected infection, sepsis-induced … Reference 4
PROWESS: Mortality Benefit
Mortality benefit greatest in patients with APACHE II >25 … Reference 4
#5: Angus DC, Laterre PF, Helterbrand JD, Ball DE, Garg R, Bernard GR. … Reference 12 and 13
Wong-Beringer A, et al. Am J Health Syst Pharm. 2003;60:1345-52;
Jacobi J.
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psnet.ahrq.gov/issue/critical-incident-reviews-significant-adverse-event-reports-and-action-plans
June 26, 2019 - Reference No: 201100433. … Reference No: 201100433. … Reference No: 201100433.
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psnet.ahrq.gov/issue/how-create-my-medicines-list
December 24, 2008 - This tool provides a printable template and step-by-step instructions for patients to create a visual reference
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psnet.ahrq.gov/issue/access-clinical-information-bedside
March 16, 2022 - The lack of access to health information technology at the bedside, and reference to the patient’s wristband
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - www.ncbi.nlm.nih.gov/pubmed/7790981
Relationship Between Medication Errors and ADEs
See Notes for reference … Identifying root causes of error is more important than determining who was involved
See Notes for reference … labeling, packaging, and nomenclature
Drug standardization, storage, and monitoring
*
See Notes for reference … allows for electronic prescription transmittal to a receiving pharmacy computer system
*
See Notes for reference … between pharmacist and
patient can provide a final check to
prevent medication errors
*
See Notes for reference
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - 84
Wide mediastinum 64% 44-80
Pleural effusion 16% 12-21
Displaced intimal calcification 9% 6-13
Reference … Wide mediastinum 64% 44-80
Pleural effusion 16% 12-21
Displaced intimal calcification 9% 6-13
Reference … 84
Wide mediastinum 64% 44-80
Pleural effusion 16% 12-21
Displaced intimal calcification 9% 6-13
Reference … Wide mediastinum 64% 44-80
Pleural effusion 16% 12-21
Displaced intimal calcification 9% 6-13
Reference … Wide mediastinum 64% 44-80
Pleural effusion 16% 12-21
Displaced intimal calcification 9% 6-13
Reference
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psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-quality-r18
March 08, 2023 - diagnostic systems (i.e., improving diagnostic precision through consensus, improving “truth” or diagnostic reference
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psnet.ahrq.gov/node/845651/psn-pdf
November 17, 2016 - underwent the same MRI exam at 10 local centers, plus one before and after at the
author’s institution (reference … Although each exam included at least one finding from the reference
MRI, there was variability in the
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - EMTALA does not apply to non-acute care facilities such as nursing homes or clinics
See Notes for reference … signout should be brief but thorough and include the following items (see next slide)
See Notes for reference … Patients “boarded” in the ED
Ambiguous responsibility for signout or follow-up
See Notes for reference … uncertain at best; this uncertainty is not always appreciated by admitting providers
See Notes for reference … result, inpatient providers may trust too strongly (or “anchor”) on the ED diagnosis
See Notes for reference
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - central line
PN also includes partial parenteral nutrition (PPN) and hyperalimentation
See Notes for reference … Errors in PN-use process may be more dangerous than risks with PN ingredients and mixing
See Notes for reference … Prescribing
Order review
Preparation
Labeling
Dispensing
Administration
Monitoring
See Notes for reference … can cause significant errors, especially during transitions between hospital and home
See Notes for reference … identified and resolved at frequencies similar to those with other complex medications
See Notes for reference
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psnet.ahrq.gov/issue/automated-identification-diagnostic-labelling-errors-medicine
September 23, 2020 - In comparison to the reference standard (concordance determined by experts) the automated system performance
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - and hematocrit at 30%
However, the "10/30" rule was based only on anecdotal evidence
7
See Notes for reference … Several studies have estimated the proportion of inappropriate transfusion at 24%−75%
15
See Notes for reference … vs. 23.3%)
All other negative outcomes also were less common in restrictive group
18
See Notes for reference … patients with acute coronary syndrome (myocardial infarction or unstable angina)
20
See Notes for reference … Audit with feedback
Audit with approval
New order form with criteria for transfusion
21
See Notes for reference