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ISMP Medication Safety Alert! Acute Care Edition. June 13, 2013;18:1-4.
Noting inconsistent evidence for independent double checks as a method to prevent medication errors, this newsletter article outlines best practices for double checks to ensure medication safety.
Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
Developing a systematic approach to safer medication use during pregnancy: summary of a Centers for Disease Control and Prevention–convened meeting.
Broussard CS, Frey MT, Hernandez-Diaz S, et al. Am J Obstet Gynecol. 2014;211:208-214.e1.
Reducing the risk of adverse drug events in older adults.
Pretorius RW, Gataric G, Swedlund SK, Miller JR. Am Fam Physician. 2013;87:331-336.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Eliminating Catheter-Associated Urinary Tract Infections.
Chicago, IL: Health Research & Educational Trust; July 2013.
Balancing "no blame" with accountability in patient safety.
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
Independent double checks: worth the effort if used judiciously and properly.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
ISMP Guidelines for Safe Preparation of Compounded Sterile Preparations.
Horsham, PA: Institute for Safe Medication Practices; 2016.
ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.
Horsham, PA: Institute of Safe Medication Practices; 2016.
Standardize 4 Safety.
American Society of Health-System Pharmacists.
Explicit and Standardized Prescription Medicine Instructions.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
Antimicrobial stewardship: another focus for patient safety?
Tamma PD, Holmes A, Ashley ED. Curr Opin Infect Dis. 2014;27:348-355.
Preventing infection from the misuse of vials.
Sentinel Event Alert. June 16, 2014;(52):1-6.
Back to basics: preventing surgical site infections.
Spruce L. AORN J. 2014;99:600-611.
ASPEN parenteral nutrition safety consensus recommendations: translation into practice.
Ayers P, Adams S, Boullata J, et al. Nutr Clin Pract. 2014;29:277-282.
Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome?
Hagerman NS, Varughese AM, Kurth CD. Curr Opin Anaesthesiol. 2014;27:323-329.
Standardization in patient safety: the WHO High 5s project.
Leotsakos A, Zheng H, Croteau R, et al. Int J Qual Health Care. 2014;26:109-116.
State-Wide Initiative to Standardize the Compounding of Oral Liquids in Pediatrics.
Michigan Pharmacists Association.
Improved obstetric safety through programmatic collaboration.
Goffman D, Brodman M, Friedman AJ, Minkoff H, Merkatz IR. J Healthc Risk Manag. 2014;33:14-22.
A mislabeling event with batched drugs: the unintended consequences of practice changes.
ISMP Medication Safety Alert! Acute Care Edition. 2014;19:1-3.
Implementing AORN recommended practices for medication safety.
Hicks RW, Wanzer LJ, Denholm B. AORN J. 2012;96:605-622.
ASPEN parenteral nutrition safety consensus recommendations.
Ayers P, Adams S, Boullata J, et al; American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2014;38:296-333.
Measure twice, cut once.
Atkinson WK. AORN J. 2013;98:77-80.
Practices to prevent venous thromboembolism: a brief review.
Lau BD, Haut ER. BMJ Qual Saf. 2014;23:187-195.
Medication errors in the management of anaphylaxis in a pediatric emergency department.
Benkelfat R, Gouin S, Larose G, Bailey B. J Emerg Med. 2013;45:419-424.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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