-
psnet.ahrq.gov/node/863212/psn-pdf
February 28, 2024 - unDerstandIng the cauSes of mediCation errOrs and
adVerse drug evEnts for patients with mental illness in
community caRe (DISCOVER): a qualitative study.
February 28, 2024
Ayre MJ, Lewis PJ, Phipps DL, et al. unDerstandIng the cauSes of mediCation errOrs and adVerse drug
evEnts for patients with mental illness in …
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psnet.ahrq.gov/node/36867/psn-pdf
August 31, 2011 - Multidisciplinary approach to inpatient medication
reconciliation in an academic setting.
August 31, 2011
Varkey P, Cunningham J, O'Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation
in an academic setting. Am J Health Syst Pharm. 2007;64(8):850-4.
https://psnet.ahrq.gov/issue/multid…
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psnet.ahrq.gov/node/37837/psn-pdf
June 11, 2008 - Testing process errors and their harms and
consequences reported from family medicine practices: a
study of the American Academy of Family Physicians
National Research Network.
June 11, 2008
Hickner J, Graham DG, Elder NC, et al. Testing process errors and their harms and consequences
reported from family medicin…
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psnet.ahrq.gov/node/36457/psn-pdf
May 27, 2011 - Controversies surrounding use of order sets for clinical
decision support in computerized provider order entry.
May 27, 2011
Bobb AM, Payne TH, Gross PA. Viewpoint: controversies surrounding use of order sets for clinical decision
support in computerized provider order entry. J Am Med Inform Assoc. 2007;14(1):41-7.…
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psnet.ahrq.gov/node/39579/psn-pdf
June 11, 2014 - Outpatient adverse drug events identified by screening
electronic health records.
June 11, 2014
Gandhi TK, Seger AC, Overhage M, et al. Outpatient adverse drug events identified by screening electronic
health records. J Patient Saf. 2010;6(2):91-6. doi:10.1097/PTS.0b013e3181dcae06.
https://psnet.ahrq.gov/issue/out…
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psnet.ahrq.gov/node/34775/psn-pdf
February 07, 2019 - Escape Fire: Lessons for the Future of Health Care.
February 7, 2019
Berwick DM. Washington DC: Commonwealth Fund; 2002.
https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
This report represents an edited version of Donald Berwick’s Plenary Address presented at the Institute for
Healthcare Improve…
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psnet.ahrq.gov/node/39753/psn-pdf
September 28, 2016 - Nursing care quality and adverse events in US hospitals.
September 28, 2016
Lucero RJ, Lake ET, Aiken LH. Nursing care quality and adverse events in US hospitals. J Clin Nurs.
2010;19(15-16):2185-95. doi:10.1111/j.1365-2702.2010.03250.x.
https://psnet.ahrq.gov/issue/nursing-care-quality-and-adverse-events-us-hospit…
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psnet.ahrq.gov/node/74268/psn-pdf
January 19, 2022 - Potentially inappropriate prescribing and its associations
with health-related and system-related outcomes in
hospitalised older adults: a systematic review and meta-
analysis.
January 19, 2022
Mekonnen AB, Redley B, Courten B, et al. Potentially inappropriate prescribing and its associations with
health?related …
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psnet.ahrq.gov/node/837067/psn-pdf
May 11, 2022 - Responding to safe care: healthcare staff experiences
caring for a child with intellectual disability in hospital.
Implications for practice and training.
May 11, 2022
Ong N, Long JC, Weise J, et al. Responding to safe care: healthcare staff experiences caring for a child
with intellectual disability in hospital. …
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psnet.ahrq.gov/issue/emergency-nursing-and-medical-error-survey-two-states
January 25, 2010 - December 1, 2011
Are temporary staff associated with more severe emergency department
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psnet.ahrq.gov/issue/ismp-quarterwatch-reports
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessment-communityambulatory-pharmacy
June 07, 2017 - May 11, 2017
Severe hyperglycemia in patients incorrectly using insulin pens at home.
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psnet.ahrq.gov/issue/patient-safety-24
December 01, 2011 - July 8, 2013
Are temporary staff associated with more severe emergency department medication
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psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - July 8, 2009
Antecedents of severe and nonsevere medication errors.
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - worsening respiratory status, liver abnormalities, and colonic pseudo-obstruction were all
consistent with severe … These are rare but life-threatening conditions that result from either decompensated
thyrotoxicosis or severe … Effects Score
Absent 0
Mild (agitation) 10
Moderate (delirium, psychosis, extreme lethargy) 20
Severe … 25
Congestive Heart Failure Score
Absent 0
Mild (pedal edema) 5
Moderate (bibasilar rales) 10
Severe
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - advanced care discussions
Case: Code Status Confusion
A 60-year-old woman with a history of severe … preferences in scenarios with uncertain outcomes
i.e., successful cardiac resuscitation with resultant severe
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
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psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - 2006
National Partnership for Maternal Safety: consensus bundle on support after a severe
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psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - September 12, 2016
ALERT: reports of severe harm after intravenous administration of