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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 - 9 of 9 Results
Cohen MR.
This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended consequences of computerized provider order entry (CPOE), and details recent changes to similarly named medications.
Fanikos J, Cina JL, Baroletti S, et al. Am J Cardiol. 2007;100:1465-9.
This study noted two adverse drug events (ADEs) per 100 patient admissions in hospitalized cardiac patients. Preventable ADEs most frequently occurred during medication administration, and cardiovascular agents and anticoagulants were the most common drug classes involved. Interestingly, the most preventable ADEs occurred between 7:00 AM and 9:00 AM, during handoffs between nurses at shift change. The authors advocate for prevention strategies around medication administration and nursing shift changes to reduce the potential for errors.
WebM&M Case September 1, 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.