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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 47 Results

Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.  

Articles in this special issue examine parenteral nutrition administration and provide tactics to improve the reliability of parenteral nutrition ordering, formulation, and delivery.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45(5);352-355.   

This monthly selection of error reports discusses incidents involving look-alike drug names, concentration dosage error, and harm related to abbreviation use.

J Patient Saf. 2010;6(1):1-47, 52-56.  

Focusing on a leadership perspective, this special issue contains numerous narrative articles regarding the National Quality Forum (NQF) Safe Practices for Better Healthcare.    
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.
This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44(10):847-853.
This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.
Cohen MR. Hosp Pharm. 2009;44(8):654-656.
This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.
Cohen MR.
This monthly selection of reports discusses an error involving the routing of a printed label in the pharmacy, describes examples of drug name confusion, and highlights an obscure drug concentration change.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.
This monthly selection of medication error reports includes information about the risks of cutting medication patches, describes examples of drug name confusion, and explains the importance of indicating the purpose for the medication on prescriptions.
Cohen MR.
This monthly selection reports on pump programming errors that led to overdoses of patient-controlled analgesia (PCA), miscommunication regarding dose and indication for alteplase, and a warning to not use empty prelabeled syringes.

Jt Comm J Qual Patient Saf. 2008;34(12):691-712.

The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2008 honorees are Michael R. Cohen, RPh, MS, ScD; Dennis O'Leary, MD; The RAND Corporation and University of California at Los Angeles School of Medicine; National Coordinating Council for Medication Error Reporting; Anthem Blue Cross and Blue Shield of Virginia; and New York City Health and Hospitals Corporation. The awards were presented at the National Quality Forum's annual meeting on October 16, 2008 in Arlington, VA.
Cohen MR.
This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child. 
Cohen MR, Smetzer JL. Hosp Pharm. 2008;43:353-356.
This monthly selection of error reports describes factors contributing to iatrogenic methadone overdoses and adverse events associated with injectable colchicine.