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Patient Safety Network

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

    … Enteral Nutr. 2012;36(2 Suppl):1S-62S.   … DA … JI … AT … MR … MH … SM … J … KF … E … JD … B … ES … JM … P … LA … GS … D … Andris … Boullata … Cassano … Cohen … DeLegge … Durfee … Gervasio … Gumpper … Hilmas … … … Sacks … Seres … DA Andris … JI Boullata … AT Cassano … MR Cohen … MH DeLegge … SM Durfee … J Gervasio … KF Gumpper … …
    NQF Safe Practices: 2010 Updates.
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    • J Patient Saf. 2010;6(1):1-47, 52-56.  

    … … CR … D … A … J … L … S … S … D … DW … WW … LH … PB … C … MR … J … ME … D … B … P … A … S … Quaid … Thao … Denham … … … Classen … Bates … George … Burgess … Angood … Keohane … Cohen … Dingman … Foley … Ford … Martins … O'Regan … … Bates … WW George … LH Burgess … PB Angood … C Keohane … MR Cohen … J Dingman … ME Foley … D Ford … B Martins … P …
    ISMP medication error report analysis.
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    • 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.
    ISMP medication error report analysis.
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    • 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.
    ISMP medication error report analysis.
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    • 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.
    ISMP medication error report analysis.
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    • 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.
    ISMP medication error report analysis.
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    • 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.
    ISMP medication error report analysis.
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    • 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.
    2008 John M. Eisenberg Patient Safety and Quality Awards.
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    • Jt Comm J Qual Patient Saf. 2008;34(12):691-712.

    … safety and quality. The 2008 honorees are Michael R. Cohen, RPh, MS, ScD; Dennis O'Leary, MD; The RAND Corporation … J Qual Patient Saf. 2008;34(12):691-712. … Audet AMJ; … MR … NS … DD … WM … L … R … KL … R … CM … JF … AD … R … Cohen … … Barger … Raju … Jacobs … Schick … Aviles … Walker … MR Cohen … NS Wenger … DD Cousins … WM Heath … L Gilbert … R …
    ISMP medication error report analysis.
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    • 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. 
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