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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

Making Healthcare Safer III Report

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Perspective on Safety March 30, 2020

This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.

In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD

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Perspective on Safety March 30, 2020

Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.

This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.

This monthly article discusses incidents involving dosing errors and describes strategies to promote the safe use of oral syringes.

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.

This monthly selection of error reports discusses incidents involving incomplete administration of a two-part pediatric vaccine and drug name confusion.

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.

This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing.

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 error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.

ISMP medication error report analysis.

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Cohen MC. Hosp Pharm. 2009;44(5):374-378.

This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.

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.

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.

ISMP medication error report analysis.

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Smetzer JL; Cohen MR.

This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.

ISMP medication error report analysis.

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Smetzer JL, Cohen MR. Hosp Pharm. 2008;43(10);788-792.

This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.

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.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports addresses examples of unclear dose preparation instructions, potential insulin storage mix ups, and drug name confusion.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports includes examples of errors due to drug labels and dosage as well as danger with look-alike, color-coded eye medications.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports includes examples of look-alike/sound-alike medications and a discussion of immunosuppressant dosing errors.

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